The urological complications of renal transplantation: an 11-year-experience at Ramathibodi Hospital

From February 1986 to December 1996, renal transplantation was performed on 344 patients at Ramathibodi Hospital. The urological complications were retrospectively analyzed in 335 patients (338 renal transplants), 9 patients were lost to follow-up. There were 227 males and 108 females with age ranging from 15 to 62 years (mean age 40.28 years). There were 207 cadaveric and 131 living-related graft donors. The ureteroneocystostomy was performed either by modified Politano-Leadbetter (93 cases) or extravesical technique (245 cases). There were 23 cases of urological complications: ureterovesical anastomotic leakage 6, ureteric obstruction 6, vesicoureteric reflux 4, significant bleeding from ureterovesical anastomosis 3, renal infarction with fistulas 2, hydronephrosis due to blood clot retention and swelling of the anastomosis, requiring temporary double J stenting 2. The analysis was done by dividing the patients into 3 groups, the first and second groups consisted of 100 cases each and the third group consisted of 138 cases. The urological complications in the groups were 10 per cent, 9 per cent and 2.89 per cent respectively. There was a statistically significant difference between the first two groups combined and the third group in terms of complications (p < 0.025). The urological complications of living-related cases were 9 (6.87%), and of cadaveric cases were 14 (6.76%). There was no significant difference of the complications between living-related and cadaveric transplants (p < 0.05). The comparative results of the ureteric complications of the extravesical technique were significantly less than the modified Politano-Leadbetter technique (4.49% vs 10.75%), (p < 0.05). In conclusion, the extravesical technique of ureterovesical anastomosis was superior than the modified Leadbetter-Politano technique in terms of post-operative ureteral complications.

Antenatal and perinatal uro-nephrology: current questions and dilemmas

The development of antenatal ultrasonography and the detection of fetal uropathies has created a new field for paediatric urologists. The embryology and physiology of the fetal renal tract is still poorly understood. It is, however, recognised that delays in the maturation of the renal system can lead to transient dilatation of the urinary tract. Structural and functional anomalies can also result in dilatation, but these are permanent. The ability to distinguish between the transient and permanent impairments to urine flow represents a diagnostic challenge. This review article discusses the pathophysiology of urine flow impairment, antenatal detection and the postnatal management of the common congenital uropathies.

A Pascal-based decision support system model for diagnosis and treatment processes in urology

This program is designed for a urologist as a Decision Support System to facilitate the pre-diagnosis and identify the definite diagnosis as quickly as possible with the help of symptoms and physical examination by taking into consideration all the possible diseases with cross-questioning. The aim is to enable the physician to display on the monitor all the possible diseases causing the arising symptoms by entering the symptoms and the physician's observations into the database with "yes" or "no" type answers.

The implementation of clinical paths for six common urological procedures, and an analysis of variances

OBJECTIVE

To evaluate the outcomes of treatment after implementing clinical paths for six common urological procedures, and analyse the variances from these paths.

PATIENTS AND METHODS

The study comprised 1006 consecutive patients treated according to the recommendations of the clinical path for six common urological procedures; the results of treatment were compared with those from 1006 patients treated by the same physicians before implementing the clinical paths. Total admission charges were divided into five categories, i.e. operation and anaesthesia, laboratory, radiology, pharmacy and other. The differences in these five categories before and after implementation were determined; the variance data were also tracked and analysed. Five quality indicators were monitored during implementation and compared with the data before implementation.

RESULTS

The mean length of hospital stay (LOS) and admission charges were significantly lower (P=0.03 and P<0.01) after implementation. The charges for laboratory, radiology, pharmacy and other were significantly decreased after the use of clinical paths. The common variations from the clinical paths were patient-related variance (33%) and discharge variance (26%). Variances affecting the LOS only or the admission charge only were more common than those affecting neither the LOS nor admission charges (both P<0.01), or both (both P<0.01). After implementation, the results of the five quality indicators were significantly improved and the number of patients with surgical complications was significantly reduced (P<0. 01), but the mortality and readmission rate did not increase.

CONCLUSIONS

The implementation of clinical paths for six common urological procedures decreased the LOS, admission charges and surgical complications, and improved the quality of care. During implementation, variances can affect the LOS and/or admission charges.

Management of urinary complications in Crohn's disease

Among the 127 patients who underwent surgical treatment for Crohn's disease at Tohoku University Hospital, urinary complications were noted in 13 patients (10.2%), including urolithiasis in 6 patients (4.7%), a ureteral obstruction in 4 (3.1%), and urinary fistula in 3 (2.4%). In patients with urolithiasis, conservative therapy was effective. An ureteral obstruction was detected on the right side in all 4 of these cases because of the inflamed terminal ileum. In 2 of the 4 cases, the symptoms improved by either preoperative total parenteral nutrition or elemental diet therapy. A resection of the inflamed intestine was necessary in all cases. In patients with urinary fistulas, a resection of the inflamed intestine combined with a reconstruction of the urinary tract was carried out after total parenteral nutrition. In conclusion, conservative therapy with preoperative total parenteral nutrition or elemental diet therapy proved to be effective for a ureteral obstruction since it improved the intestinal inflammation. As a definitive treatment, surgery is still necessary for the management of urinary fistulas and ureteral obstruction. Based on our findings, patients with urolithiasis in Crohn's disease should thus be treated conservatively in the same way as patients without Crohn's disease.

[Urologic importance of interventional radiology techniques]

In radiology several therapeutical methods were developed and introduced into clinical routine in the last 10 to 15 years. In part these techniques are in competition with established surgical procedures although their main advantage is significantly less invasion. For the urologist diagnostic radiological procedures like selective blood sampling from renal or suprarenal vessels for hormone determination or CT-guided biopsy of retroperitoneal tumors are of special interest as well as procedures with therapeutic aims such as placement of drainage-tubes, percutaneous therapy of varicoceles and arterial endovascular interventions for hemorrhage or vascular wall stenosis. The role of these interventional techniques relevant for urology is described and critically discussed.

Urethral dilation in women: a questionnaire-based analysis of practice patterns

OBJECTIVES

To assess current practice patterns among urologists and to determine the perceived efficacy of urethral dilation. Urethral dilation has been advocated as a treatment for a variety of urologic disorders in women for several decades. Recent changes in Medicare reimbursement have again focused attention on this issue.

METHODS

A 15-item questionnaire was mailed to all urologists actively practicing in the state of Texas (n = 642). The questionnaire consisted of 12 items about indications for, technique of, and outcome of urethral dilation, and three demographic questions regarding location and type of practice and number of years since completing residency.

RESULTS

A total of 194 physicians completed and returned the questionnaire (30%). Overall, 48.2% of practitioners used dilation six or fewer times during the past year; 23.7% reported having used it more than 30 times. Most urologists used dilation for urethral syndrome only (61.1%), although urethral stricture was also a frequently reported condition requiring dilation (29%). Most urologists trained within the past decade (60.9%) reported never offering dilation for urethral syndrome; only 34.2% of the remainder never offered it (P = 0.002). Urologists normally performed this procedure with local or no anesthesia (85%) and most commonly dilated to 32F (45%). Overall, 21% of urologists trained more than 10 years ago considered dilation very or extremely successful in treating urethral syndrome; 0 of 42 trained more recently considered it to be this successful (P = 0.014).

CONCLUSIONS

The use of urethral dilation in women remains controversial. Recently trained urologists use it less frequently and find it less efficacious than those who have been practicing for longer periods. Since such obvious biases exist, it is imperative that the clinical merit of urethral dilation be carefully scrutinized.

Phytotherapeutic agents in the treatment of lower urinary tract symptoms: a demographic analysis of awareness and use at the University of Chicago

OBJECTIVES

To assess awareness and use of phytotherapeutic agents in treating lower urinary tract symptoms (LUTS).

METHODS

A survey was conducted of 1280 patients presenting to the University of Chicago Hospitals urology clinic. The questions pertained to age, race, educational level, and use of prescription and nonprescription medications for urinary symptoms.

RESULTS

Of 1264 patients filling out the surveys correctly, the 51 to 60-year-old age range demonstrated the greatest percentage of use of these agents. Whites were nearly twice as likely as their African American counterparts to use medicinal botanicals. Men with college or graduate school degrees were 1.5 times as likely to use medicinal botanicals in treating LUTS. More than 50% of men using phytotherapeutic drugs were also taking prescription medications for the urinary symptoms.

CONCLUSIONS

There is significant use of phytotherapeutic agents in men with LUTS, although there is variability in their use between patient groups. American physicians need some understanding of these agents to best advise and treat their patients.

The physicochemical basis of urinary catheter encrustation

OBJECTIVES

To determine the relationship between urinary pH and Ca2+ solubility in urine samples from patients who experienced either frequent ('blockers') or infrequent ('nonblockers') catheter blockage by crystalline deposits of divalent cation salts.

MATERIALS AND METHODS

Fresh urine samples from 'blockers' and 'nonblockers' were collected and the ionic calcium concentration ([Ca2+ ]) measured using a Ca2+-selective electrode whilst the urinary pH was increased in 0.25 increments between 4.75 and 9.00. The pH at which crystallization occurred (nucleation) was determined and crystal composition analysed.

RESULTS

The mean (sd) voided urinary pH of catheter 'blockers' was significantly more alkaline than that from 'nonblockers', at 7.63 (0.64) and 5.97 (0.80), respectively (P=0. 001). The nucleation pH of catheter 'blockers' was significantly more acid than in 'nonblockers', at 7.43 (0.73) and 6.45 (0.65), respectively (P=0.005). Urine from 'blockers' had significantly more Ca phosphate and Mg ammonium phosphate crystals. 'Blockers' were further divided into two subsets with and without urease-based urinary tract infection; both showed a decrease in the nucleation pH.

CONCLUSION

In the urine from 'nonblockers' there is a wide safety margin between voided and nucleation pHs; this margin was less in the urine from 'blockers'. This reduction in the safety margin arises partly because the voided pH in those with a urinary tract infection is more alkaline. However, the decrease in the nucleation pH also suggests that a fundamental property of urine is altered, which reduces Ca2+ solubility at more neutral pH values. The long-term goal is to increase the nucleation pH of catheter 'blockers' and increase the margin of safety.

Treatment of estrogen deficiency symptoms in women surviving breast cancer. Part 4: Urogenital atrophy, vasomotor instability, sleep disorders, and related symptoms

There are several million breast cancer survivors worldwide. In the United States, 180,000 women were diagnosed with breast cancer in 1997, and approximately 97,000 of these women have an extremely low chance of suffering a recurrence of their cancer. With an average age at diagnosis of 60 years and a 25-year expected duration of survival, the current number of breast cancer survivors in the United States may approach 2.5 million women. Since breast cancer is now being detected at an earlier stage than previously and since adjuvant chemotherapy may cause ovarian failure, an increasing number of women are becoming postmenopausal at a younger age after breast cancer treatment. This conference was convened in September 1997 to consider how menopausal breast cancer survivors should be treated at the present time and what future studies are needed to develop improved therapeutic strategies. A total of 47 breast cancer experts and 13 patient advocates participated. The proceedings of the conference are being published in six installments in successive issues of ONCOLOGY. This fourth part focuses on the treatment of urogenital atrophy, vasomotor instability, sleep disorders, and other related symptoms.