Iatrogenic urological injuries complicating obstetric and gynaecological procedures.

INTRODUCTION: Urinary tract injuries are known complications of pelvic surgeries. Although a few instances have been noted, they remain a source of great concern to surgeons due to their associated morbidity and occasional mortality. We report our experience with the management of iatrogenic urological injuries that complicated obstetric and gynaecological surgeries over a five-year period. METHODS: We reviewed all cases of urological injuries managed in our unit that were deemed to be of obstetric and gynaecological origins within the study period. RESULTS: A total of 16 patients were identified as having iatrogenic urological injuries following obstetric and gynaecological surgeries. Only four patients presented early. Five patients had injuries to the bladder, while 12 had ureteric injuries; one of the 16 patients had both types of injuries. Seven cases of ureteric injuries affected only the left ureter, while three were bilateral and two affected the right ureter. One patient with a vesicovaginal fistula (VVF) was successfully managed by urethral catheter drainage alone. Three patients had transabdominal repair of the VVF, while ten had ureteroureterostomy and one had diversion procedure. Simple nephrectomy was performed for one patient with a non-functioning kidney. CONCLUSION: Iatrogenic urological injuries are still common in our environment. In order to reduce the risk of injury, adequate preoperative preparation is recommended and meticulous surgical technique based on proper understanding of the anatomy of the urogenital system should be practised by the surgeon.

Twenty-one-year-old male with congenital anomalies, obstructive uropathy and chronic renal failure: is this a case of Townes Brocks syndrome?

Townes Brocks syndrome is an autosomal dominant multiple malformations syndrome comprising of ear anomalies/hearing loss, limb defects, anal, genitourinary, eye, spine anomalies, heart defects and sometimes mental retardation. This report presents the case of a 21-year-old secondary school leaver as a likely case of Townes-Brocks syndrome. He was born with congenital abnormalities consisting of fixed flexion deformities of hands, wrist and elbows, urethral meatal stenosis, scoliosis and aortic stenosis. He was diagnosed with obstructive uropathy at the age of 19 years and subsequently developed chronic renal failure. The report aims to highlight the need for early recognition of potentially preventable conditions, which, if left unattended to, can lead to unnecessary fatality.

Appendico-vesicostomy in tile management of complex vesico-vaginal fistulae.

Complex vesico-vaginal fistulae (VVFs) continue to complicated prolonged obstructed labour in this country. Recently a young lady presented to us with a huge VVF, associated with loss of the urethra and bladder neck, severe gynaetresia and recto-vaginal fistula. Her VVF was successfully managed by an appendico-vesiscostomy.

Prognostic factors in Saudi children with posterior urethral valves.

Posterior urethral valves (PUV) account for a sizeable proportion of children with chronic renal failure. Several criteria have been identified as predictive of future renal function in children with PUV. We compared the presenting features and initial treatment in two groups of Saudi children treated for PUV, with the aim of identifying any factors that might account for the differences observed in their renal function. One group (group A, 19 patients) had a serum creatinine of 80 micromol/l or less at follow-up and the other (group B, 13 patients) had higher levels. There was no significant difference in age or weight at presentation, incidence and severity of reflux, urinary tract infection, or type of primary treatment (valve ablation versus vesicostomy) between the two groups. However, after 5-7 days of catheter drainage, the mean serum creatinine level was 88+/-62 micromol/l for patients in group A compared with 172+/-77 micromol/l for those in group B (P<0.0001). This difference was highly significant. Linear regression analysis of post-drainage creatinine and serum creatinine at last follow-up showed a correlation coefficient of 0.7171 (P<0.0001). Hence the serum creatinine level after catheter drainage correlated strongly with renal function during short-term follow-up of Saudi children with PUV. This might help in the selection of the optimal initial therapy and provide some basis for prognostication.

Pyelovenous fistula: an uncommon cause of 'essential haematuria'.

Haematuria from obscure lesions of the kidney sometimes pose both diagnostic and therapeutic challenge. Recently, we managed a patient in whom a confident diagnosis of pyelovenous fistula was made.

Major injuries to the urinary tract in association with childbirth.

This retrospective study was designed to determine the incidence of major injuries to the urinary tract that occur during parturition and to assess their management. Twenty one such injuries were managed at the maternity wing of the Riyadh Medical Complex in a four-year period. They occurred during a total delivery of 48,693. This gives an incidence of major urinary trauma of 43 per 100,000 births. There were 4,622 deliveries by caesarean section, giving a section rate of 9.5%. Of ten cases of severe bladder injuries, seven occurred in association with ruptured uteri, and three at repeat caesarean sections. One case of bladder rupture involved injury to the ureters, and another was associated with vaginal laceration and traumatic vesico-vaginal fistula. All bladder injuries were discovered either on the table or soon after delivery. Ten women sustained ureteric injuries. Five injuries occurred during caesarean section, three at caesarean hysterectomies, two were avulsed from a ruptured bladder and another was ligated during repair of a deep cervical laceration. Only one case of ureteric injury was made intra-operatively. The others (90%), were discovered in the early puerperium, ranging from five to twenty one days. There was one case of rupture of a diseased kidney during labour. She presented soon after delivery and had nephrectomy. Haemorrhage was profuse in many cases and warranted hysterectomy in six cases, internal iliac artery ligation in three cases, and both procedures in one case. Assessment of viability of tissues and integrity of the ureters was made difficult by bleeding. Successful bladder repair was achieved in nine out of ten women employing limited excision of tissues and liberal drainage. Exploration and repair of ureteric injuries was preceded by a period of percutaneous nephrostomy drainage. This approach was associated with good results.

Management of uretero-pelvic obstruction in developing countries.

Congenital pelvi-ureteric junction (PUJ) was found in 29 of 36 renal units explored for impaired pelvic drainage in 34 adults. There was a primary nephrectomy rate of 8.4%, and follow up was poor. The widespread use of ultrasound scan has led to an increase in the number of children with equivocal PUJ obstruction. Where surveillance is inadequate, as is the case in developing countries, we suggest that early operation might lead to better renal salvage in such cases.

Management of impotence in a developing country.

Three hundred and seventy five impotent men attended our Andrology clinic between July 1988 and June 1993. Their ages ranged from 20-89 years. Associated factors were diabetes mellitus, testicular failure, trauma, venous leak and hyperprolactinaemia. We categorised them into subgroups of highly educated men with manual dexterity and financial ability but impairment of manual dexterity, financially able but illiterate men, and illiterate poor with or without manual dexterity. Penile prostheses were implanted in 15; 48 were treated with vasoactive substances; 4 with vacuum devices and two had ligation of venous leaks. However, 297 (79%) men did not get the treatment best suited for their problems and received only supplementary hormones and/or psychological reassurance. In the developing countries, the selection of the appropriate treatment modality for impotence is compounded by considerations of economic, social and educational factors.

The posterior urethral valve uropathy: results of treatment.

Nineteen children treated for posterior urethral obstruction due to congenital valve in the University of Benin Teaching Hospital, Benin City, Nigeria, over a 9-year period have been analysed. Their ages ranged from birth to 12 years. Results show that associated kidney pathology may be irreversible even after successful excision of the valve. This determines the final prognosis, which is worse the younger the child at presentation.

The value of ultrasound in the evaluation of patients with blunt scrotal trauma.

Twenty-one men with blunt scrotal trauma managed in the Urology Department of Riyadh Central Hospital are presented. The decision for surgical exploration was strengthened by ultrasonic findings in six patients--four men with haematocoele and ruptured testicles and two with expanding extratesticular haematoma and normal testes. In addition, sonography revealed unsuspected intratesticular haematoma and disrupted tunica albuginea (without haematocoele) in two other cases. One case managed non-operatively developed a testicular abscess detected by ultrasound. Surgery confirmed the diagnoses in all nine cases that were explored. Thirteen patients were managed non-operatively, including six cases in whom sonography revealed contused testes. Hence, the value of ultrasound scanning in evaluating patients after blunt scrotal trauma was established. It complemented clinical findings and detected unsuspected testicular injury.

Missed urological injuries in children with polytrauma.

Fifteen children (11 boys and 4 girls) with severe injuries of the urinary tract were admitted to the Riyadh Central Hospital between 1990 and 1992. Their ages ranged from 2.5 to 12 years (mean 7.3 years), and their injuries were parts of multiple-organ trauma. Following resuscitation, every child was evaluated and staged by either intravenous urography, CT scan or ultrasonography or a combination of these. Commonly associated injuries were to the skeleton, spleen and liver. Two patients with ureteropelvic junction injuries and two girls with traumatic urethropaginal fistulas were not diagnosed. The delay in diagnosis contributed to an increase in morbidity. Despite modern radiological imaging, some severe injuries of the urinary tract can still be missed. Heightened awareness and thorough clinical examination are mandatory for early diagnosis of such injuries in children with multiple injuries.

Iatrogenic urogenital fistulae.

Nineteen patients with iatrogenic urogenital fistulae were treated between 1985 and 1989. All resulted from obstetric and gynaecological surgery. Major symptoms were leakage of urine through the vagina, menouria and perineal dermatitis. The fistulae formed after treatment for benign conditions in 18 patients. Fistulae complicating cancer surgery were uncommon. All patients with uretero-vaginal fistulae underwent preliminary percutaneous nephrostomy. Twelve patients underwent reconstruction using either the Boari-Ockerblad flap (5), uretero-neocystostomy (4) or other techniques (3), all with excellent results. Most of the remaining patients had treatment elsewhere. We consider that preliminary diversion, followed by delayed reconstruction, is a valuable option in the management of uretero-vaginal fistulae.

Testicular infarction complicating strangulated inguinal herniae in Nigerian children.

Between 1985 and 1990 30 children were operated on for strangulated inguinal herniae in the University of Benin Teaching Hospital, Benin City, Nigeria. Six of the children (20%) had testicular infarction secondary to the strangulated hernia. Half of the children with infarcted testes had viable bowel at operation. The surgeon dealing with African children with strangulated herniae needs to be sensitised to this condition and the possibility that the testis may well be infarcted before the intestines.

Unusual bilateral renal histiocytosis. Extranodal variant of Rosai-Dorfman disease.

A 37-year-old Bangladeshi presented with large bilateral masses involving the hilus of the kidneys. No lymphadenopathy was noted. Nephrectomy was performed. Histopathologically, it revealed a lymphohistiocytic and plasma cell inflammatory tumoral proliferation with characteristic lymphophagocytosis by the S100-positive-CD1-negative histiocytes. Extranodal presentation of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) should be entertained in the differential diagnosis of bilateral masses involving the kidneys.

Incidence of undescended testis in a population of children at Benin City

One thousand; eight hundred and ninety-six children aged 6 to 12 years were examined for undescended testis. The incidence was found to be 0.8in the 6 year olds; and also in the 7 and 8 years groups. The overall incidence was 0.4. A differential intrascrotal descent rate was also discovered between the right and left testes; by observations of position of testis in scrotum in each age group: thus while at the age of 6 years 9.4of the left testes and 6of the right testes had touched the base of the scrotum; at the age of 12 years 88.3of the left testes but 95.7of the right testes lay in the base of the scrotum

Non-germ cell testicular tumours in Nigerians.

Non-germ cell testicular tumours are reported to be more common in peoples of Negroid and Asian descent than in Caucasians. This group of tumours comprised seven of sixteen testicular tumours seen in a ten-year period at the University of Benin Teaching Hospital, Benin City, Nigeria. However, unlike experiences elsewhere in Africa and the West Indies where paratesticular tumours accounted for a majority of these tumours, malignant lymphomas constituted over 70% of non-germinal testicular tumours in our population.

Abnormal findings associated with undescended testis in Nigerian children.

Children between the ages of 6 years and 12 years numbering 2200, were examined for general physical development and external abnormality to correlate these anomalies with frequency of undescended testis. Whereas the overall frequency of undescended testis in this population was 0.5%, this condition was present in 1% of boys with peri-umbilical hernia. Undescended testis should be looked for in children with external congenital anomalies, particularly of the anterior abdominal wall.