Use of 99m Tc-DTPA Scintigraphy in Evaluation of Ureteral Laceration Due to Transurethral Lithotripsy in a Patient with Nephrolithiasis

Transurethral lithotripsy (TUL) procedure via ureteroscopy as an invasive method for nephrolithiasis treatment would lead to urinary tract injuries. In this reported case, the procedure caused severe damage to the left ureter that was detected by ^99m Tc-diethylenetriaminepentaacetic acid ( ^99m Tc-DTPA) scan. Generally, the TUL procedure through the ureter scope is used to manage urinary tract stones. In this case, the TUL was performed on a patient with a history of nephrolithiasis. Following that, she was accompanied with abdominal pain and discomfort, so ^99m Tc-DTPA scintigraphy was performed to evaluate the urinary tract system. The scintigraphy showed a severe damage to the left ureter that finally resulted in autotransplantation. The control ^99m Tc-DTPA scintigraphy performed 3 weeks after revealed no visible urinary leakage. In this case, the ^99m Tc-DTPA scan prevented the patient from dangerous complications. So, ^99m Tc-DTPA scan could be performed after TUL and ureteroscopy to detect probable risks.

A Randomized Crossover Pilot Study Examining the Effect of Carvedilol and Terazosin plus Enalapril on Urinary Symptoms of Patients with Hypertension and Benign Prostatic Hyperplasia

PURPOSE

The present study aims to assess and compare the effects of carvedilol and terazosin plus enalapril on lower urinary tract symptoms (LUTS), the urine flow, and blood pressure (BP) in patients with moderate hypertension (HTN) and benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

In this randomized crossover trial, a total of 40 men with HTN and LUTS symptoms were enrolled. The first group was treated with carvedilol, and the second one received terazosin plus enalapril. After eight weeks of treatment, the patients experienced a one-month washout period, and the treatments changed and continued for eight weeks. To diagnose BPH in the study, the international prostate symptom score (IPSS) questionnaire was used. Moreover, the prostate-specific antigen (PSA), the post-void residual (PVR) urine volume, and the maximum urinary flow rate (Q-max using the uroflowmetry test) were measured.

RESULTS

Effect assessment results in this crossover trial illustrated neither carryover effects nor significant treatment effects on all primary outcomes (P > 0.05). Moreover, the results for the period effect indicated a significant reduction in BP (systolic and diastolic), PVR, and IPSS, yet a significant raise in Qmax.

CONCLUSION

The effects of carvedilol are similar to those of the combination of terazosin and enalapril in patients with moderate HTN and BPH in controlling LUTS. Carvedilol could be used as an appropriative drug in patients with moderate HTN and cardiac problems with LUTS of BPH. Further studies are recommended to be conducted to investigate and compare the efficacy of carvedilol with that of other alpha-blockers with a larger sample size and over a longer period of time.

Successful Kidney Transplant From a Brain Stem-Dead Donor Due To Lethal Methanol Poisoning

Kidney replacement is the best treatment modality for chronic renal failure; however,the greatest obstacle for transplant is the scarce number of donor organs. In the United States and Europe, less than 1% of organs for transplant are provided from patients with lethal poisoning. In this paper, we present a successful kidney transplant from a donor with methanol poisoning. A 38-year-old-man who had methanol poisoning developed brain stem death after unsuccessful treatment and was a candidate to be a kidney donor for transplant to a 27-year-old male patient with chronic renal failure. Three weeks after kidney transplant, the recipient was discharged with good kidney function. We suggest that it may be possible to consider lethal methanol poisoning for kidney donation.

The Effects of Religious and Cultural Beliefs on Muslim Transplant Candidates During the Pretransplant Waiting Period

Background:

Awaiting organ transplantation can be stressful, and pretransplant candidates’ religious and cultural beliefs can influence how they adapt to the stress. While little is known about the effect religious and cultural beliefs have on the pretransplant waiting period, virtually nothing is known regarding whether and how Shia Muslim patients’ religious and cultural beliefs facilitate more positive patient outcomes while they await transplantation. Therefore, it is important for nurses and other health care providers to understand transplant candidates’ experiences dealing with the stressors that present themselves during the pretransplant waiting period, especially how their religious and cultural beliefs affect their adaptation to the stressors.

Aim:

The purpose of this study was to explore the lived experience of Shia Muslim organ transplant candidates regarding how their religious and cultural beliefs affect their adaptation to the pretransplant waiting period.

Sample:

A purposeful sample of 11 Shia Muslim organ transplant candidates who were on an organ transplant waiting list in Iran (kidney,n= 4; heart,n= 4; liver,n= 3) was recruited.

Method:

A qualitative research design using the hermeneutical phenomenological approach was utilized in this study. In-depth unstructured interviews were conducted by one of the authors (ZS) in different locations across Iran.

Results:

Data analysis led to the development of six themes: “the misty road of organ transplantation,” “to accede to organ transplantation despite religious conflict,” “one step away from death,” “the master key of liberation,” “fear of the unknown,” and “reliance on God.”

Nursing Implications:

The findings of this study will help nurses understand the religious and cultural meaning associated with stressors experienced by Shia Muslim patients awaiting organ transplant. This information can assist nurses to develop plans of care that include patient-specific interventions that take into consideration the patients’ religious and cultural beliefs.

Conclusion:

Shia Muslim patients awaiting organ transplantation experience feelings that are often in conflict with their religious and cultural beliefs. However, the patients’ reliance on God during the pretransplant waiting period facilitated healthier attitudes regarding transplantation.

The Relationship between Carotid and Femoral Artery Intima-Media Thickness and Histopathologic Grade of Atherosclerosis in Patients with Chronic Kidney Disease

BACKGROUND/AIMS

Variability in the grade of atherosclerosis among patients with chronic kidney disease (CKD) could affect the ultrasound measurements of intima media thickness (IMT). We sought to investigate IMTs of carotid (cIMT) and femoral (fIMT) arteries in CKD patients and assess the degree of their correlation with histopathological atherosclerosis.

METHODS

Eighty-nine out of 99 enrolled subjects completed this study. The subjects were divided into 3 groups: 34 patients with CKD (Case group), 31 with coronary artery disease undergoing coronary artery bypass graft (CABG, positive control group), and 24 healthy kidney donors (negative control group). For histopathological assessment of atherosclerosis, arterial tissue samples were obtained from the patients in each study group. The cIMT and fIMTs were measured by ultrasonography.

RESULTS

Histopathological atherosclerosis was present in 82.3, 100, and 20.8% of CKD, CABG, and donor groups respectively (p < 0.001). CKD patients had higher values of cIMT and fIMT than the donor group (p = 0.01 and 0.004, respectively). cIMT was positively correlated with the grade of atherosclerosis in the CKD group only (p < 0.001), while fIMT was correlated with the grade of atherosclerosis in both CKD and donor groups (p < 0.001 and p = 0.009 respectively). In CKD patients, cIMT >0.65 mm and femoral values >0.57 mm predicted the presence of histopathological atherosclerosis with sensitivities of 96 and 92% respectively.

CONCLUSION

Higher values of cIMT and fIMT in CKD patients are associated with higher rates and degrees of histopathological atherosclerosis. Additionally, when compared to fIMT, cIMT has a higher sensitivity for detecting atherosclerosis in CKD patients.

Is it possible to preserve the blood supply of erectile organs by anastomosis using the hypogastric artery in kidney transplantation?

Introduction

Three modalities for treating chronic kidney failure are peritoneal dialysis, hemodialysis, and kidney transplantation. Among them kidney transplantation is cost-efficient and leads to a somewhat normal quality of life. In this approach, most often the external iliac artery is selected for anastomosis, but this could be disastrous if anastomosis leads to a complication. The traditional end-to-end approach for anastomosis of the kidney artery to the internal iliac artery leads to pelvic organ ischemia. However, if the end-to-end anastomosis is replaced by an end-to-side approach, it is safer. This report discusses some cases of end-to-side anastomosis using the internal iliac artery.

Method

In ten cases of chronic kidney failure, we anastomosed the kidney artery to the internal iliac artery with an end-to-side approach.

Results

After vessels were unclamped, all patients had diuresis. Their creatinine was in normal range and was blood flow in the internal iliac artery, based on color Doppler ultrasound.

Conclusion

End-to-side anastomosis can be done in some chronic kidney failure patients if their internal iliac arteries are large enough. This approach is safer than anastomosis using the external iliac artery.

Bolus Injection Versus Infusion of Furosemide in Kidney Transplantation: A Randomized Clinical Trial

PURPOSE

Furosemide is commonly administered to increase the urinary output in patients with transplanted kidneys. This study compared the two administration routes of furosemide (bolus versus infusion) in kidney transplanted patients.

MATERIALS AND METHODS

Fifty patients who had undergone kidney transplantation in 2015 in a hospital in Tabriz, Iran, were included in this clinical trial. They were divided into two groups: bolus (120 mg stat) and infusion (4 mg/minute) groups. The primary outcome was urine onset time. Secondary outcomes were urine output volume, vital signs (blood pressure, heart rate), and electrolyte level (creatinine, blood urea nitrogen, sodium and potassium). After arterial and venous anastomoses, arterial clamp removal time and diuresis onset were recorded. Finally, theurinary output volumes of both groups were measured with regular urine bags for an hour after anastomosis. Then it was repeated each three hours for 24 hours, and eventually two and three days thereafter. Finally, all data were statistically analyzed.

RESULTS

Around 72% of the patients were men (mean age of 37.15 &plusmn; 14.67 years). Urine output was higher in bolus group but it was not statistically significant. Diuresis duration was measured after arterial declamping and its averages were 5.41 &plusmn; 3.7 minutes and 9.36 &plusmn; 7.65 minutes in bolus and infusion groups, respectively (P = .040). Furosemide bolus injection and infusion had no significant effect on creatinine, blood urea nitrogen, sodium and potassium.

CONCLUSION

Furosemide bolus injection can reduce diuresis onset time compared to furosemide infusion.

Renal Collecting System Anatomy in Living Kidney Donors by Computed Tomographic Urography: Protocol Accuracy Compared to Intravenous Pyelographic and Surgical Findings

OBJECTIVES

To evaluate the accuracy of triple-bolus computed tomography urography (CTU) as a surrogate of intravenous pyelography (IVP) for determining the anatomy of the urinary collecting system in living kidney donors.

MATERIALS AND METHODS

In an analytic descriptive cross-sectional study, 36 healthy kidney donors were recruited during 12 months. Preoperative IVP and CTU were utilized to evaluate kidneys' anatomy; major and minor calyces and variation were used as anatomical indices to compare the accuracy of CTU and IVP; the images were then compared to surgical findings.

RESULTS

Thirty-six kidney donors (92% male; mean age: 28 ± 6 years) were enrolled in this study. The kappa coefficient value was significant and almost perfect for the CTU and IVP findings in detecting the pattern of calyces (kappa coefficient 0.92, asymptotic 95% confidence interval 0.86-0.97). Anatomic variations or anomalies of the urinary collecting system included the bifid pelvis (5.6%), duplication (8.3%), and extra-renal pelvis (2.8%). Both the sensitivity and specificity of CTU in the detection of the anatomy and variations were 100%; the sensitivity and specificity of IVP were 83.3% and 100%, respectively.

CONCLUSIONS

The triple-bolus preoperative CTU can be considered an alternative to IVP for assessing the anatomy of the urinary collecting system.

Numerous Bladder Stones

An 83-year-old man with benign prostatic hyperplasia and several comorbid conditions presented with irremovable urethral Foley catheter. Plain abdominal X-ray revealed a bladder full of stones. The patient had bilateral hydronephrosis and elevated serum Creatinine level. Open vesicolithotomy was done and more than 720 stones in various shapes and sizes was removed. After removal of stone, Creatinine gradually decreased from 4.9 to 1.8 mg/dL and most of lower urinary tract symptoms were alleviated in the follow-up.

Serum and tissue endothelin-1 are independent from intima-media thickness of peripheral arteries in patients with chronic kidney disease

AIM

We aimed to study the relationship of peripheral arteries' atherosclerosis with serum and tissue endothelin-1 in chronic kidney disease patients.

METHODS

Ninety patients were enrolled, including 35 patients with chronic kidney disease (case group), 31 patients with coronary artery diseases who were candidates for coronary artery bypass grafting (positive control group), and 24 living kidney donors (negative control group). Intima-media thickness of the common carotid and femoral arteries was determined by ultrasonography. Serum and tissue endothelin-1 were measured by ELISA method.

RESULTS

The mean serum and tissue endothelin-1 levels in the donor group were significantly lower than other groups (p < 0.001 for both). The coronary artery bypass grafting group had higher carotid and femoral intima-media thickness than other groups (p < 0.001), and the chronic kidney disease group had higher carotid and femoral intima-media thickness than the donor group (p < 0.001). Regression analysis in all groups did not reveal any correlation between the carotid intima-media thickness/femoral intima-media thickness and the serum/tissue endothelin-1. There was a direct linear correlation between the carotid and femoral intima-media thickness (p < 0.001) in all groups.

CONCLUSIONS

Endothelin-1 level and intima-media thickness were higher in the chronic kidney disease patients and coronary artery bypass grafting candidates, without any correlation between endothelin-1 and peripheral arteries' intima-media thickness of both groups. Perhaps endothelin-1 rises and remains high upon endothelial damage and initiation of atherosclerosis.

Diagnostic accuracy of 64-MDCT angiography in the preoperative evaluation of renal vessels and compared with laparotomy findings in living donor kidney

INTRODUCTION

Multidetector-row computed tomography (MDCT) angiography is a reliable technique in preoperative renal anatomy evaluation in live renal donors.

OBJECTIVES

To investigate the accuracy of early arterial phase findings and compares them with intraoperative findings.

METHODS

In this prospective study, 100 potential live donors undergoing preoperative MDCT and nephrectomy during 2010-2013 were included. The examination was performed with a 64-detector scanner including early arterial and venous phase. MDCT angiography started by bolus tracking and venous phase was acquired 9 s after arterial phase. Anatomical findings and vein and artery attenuation values were recorded and arterial phase findings were compared with intraoperative findings.

RESULTS

All anatomical findings reported by MDCT in early arterial phase were confirmed by intraoperative findings with sensitivity of 100%. Right renal vein was supernumerary in 17 cases and left renal vein was circumaortic in 3 and retroaortic in 5 cases. Renal arteries had early branching in 13, two arteries in 12 and accessory in 8 cases. Vein and artery attenuation values had significant difference between early arterial and venous phase (p < 0.001).

CONCLUSION

Early arterial phase has similar results to venous phase in preoperative evaluation and intraoperative findings and could be used alone to reduce radiation dose.

Effect of lymph leakage on renal allograft outcome from living donors

Lymph leakage is a cause of prolonged fluid discharge in renal transplant patients. Lymph leakage during early post-transplantation is responsible for extracting immune substances; therefore, it may play a role in prognosis of the transplanted kidney. In this study, we aimed to investigate the effects of lymph leakage on different factors that play significant roles in renal allograft outcome. During the present case-control study, we evaluated 62 renal allograft recipients in which 31 subjects were complicated with lymph leakage and enrolled as the study group. The other 31 subjects were included in the control group who did not experience any lymph leakage during their post-transplantation period. All kidneys were transplanted from living donors. We investigated and compared the renal allograft rejection rate, hospitalization duration, serum urea, creatinine (Cr) and cyclosporine (CsA) levels, antithymoglobin (ATG) administration and treatment duration between the study and the control groups. There were no significant difference in the urea and Cr levels between the two groups (P >0.05). Early (one week) and late (one month) serum CsA levels of the study group were significantly higher than in the control group (P = 0.005 and P = 0.006). The number of days in which ATG receivers responded to therapy was significantly lower for the control group (P = 0.008). 21.93% of the study group subjects experienced allograft rejection, while this rejection probability was 28.38% for the control group (P = 0.799). Lymph leakage has no prominent role in renal function, which is estimated by Cr and urea levels in patients' serum during the days after transplantation. CsA level was higher in patients with lymph leakage, and all cases of allograft rejection were in the subjects with lymph leakage.

Effect of low dose dopamine on early graft function in living unrelated kidney donors

PURPOSE

To evaluate the effect of low-dose dopamine administration on the early function of the kidney in unrelated kidney donors after transplantation.

MATERIALS AND METHODS

In this double-blinded clinical trial, 60 adult kidney donors and 60 recipients, younger than 50 years old, were studied. Donors and recipients were randomly divided into two groups; group 1 received dopamine 3 µ/kg/min and group 2 received similar regimen of placebo. During the first 3 days postoperatively, serum levels of urea and creatinine as well as urine output and early kidney function were compared between two groups.

RESULTS

Serum levels of creatinine and urea and urine output during the first three days after the operation did not differ statistically significantly between two groups (P = .549, P = .306, and P = .375, respectively). Early kidney function was better significantly in group 1 (5.3 ± 3.2 versus 8.6 ± 8.0 hours; P = .048).

CONCLUSION

Premedication of the kidney transplant donors with low-dose dopamine accelerates early kidney function after transplantation, but has no effect on the hemodynamic status and serum levels of creatinine and urea in the donors.

Anatomy of the collecting system of lower pole of the kidney in patients with a single renal stone: a comparative study with individuals with normal kidneys

At least 5% of women and 12% of men during their lives will experience renal colic, at least once. Many theories have been suggested for the etiology of renal stones and variations in the anatomy of the collecting system have been suggested to have a role in stone formation. This study was conducted to examine the role of variation of lower pole collecting system in patients with lower pole kidney stone and compared the same in normal persons (kidney donors). Investigation for the anatomy of the lower pole of the kidney (angle between lower infundibulum and pelvis, length and diameter of the infundibulum and number and pattern distribution of calyces) was carried out using intravenous pyelogram (IVP) in 100 cases with urinary stone (study cases) and 400 persons with normal kidneys (control subjects). The study was a retrospective cross-sectional case control study. Results were analyzed by Mann-Whitney and independent sample chi square tests. The mean infundibulum-pelvic angle (IPA) in control subjects and in patients was 112.5 +/- 10.7 and 96.6 +/- 28.8, respectively. There was significant correlation between reduced angle and stone formation (P= < 0.001). The mean infundibulum-uretero-pelvic angle (IUPA) in control subjects and study cases was 53.5 +/- 12.7 and 42.6 +/- 13.4, respectively. There was significant correlation between decreased angle and stone formation (P = or < 0.001). The mean length of infundibulum of lower pole of kidney (IPIL) in controls and study patients was 22.5 +/- 4.1 and 27.5 +/- 7.7, respectively, which was statistically significant (P< 0.001). The mean number of calyces in lower pole of the kidney (LPCN) in controls and study patients was 2.6 +/- 0.6 and 3 +/- 0.9, respectively, which was statistically significant (P = or < 0.002). There was no significant correlation between distribution of calyces and stone formation (P= 0.366). Our study suggests that abnormal renal anatomy was more common in patients with lower pole kidney stone and should be considered a risk factor for forming lower pole kidney stone.

Arterial atherosclerosis in patients with chronic kidney disease and its relationship with serum and tissue endothelin-1. [corrected]

Instruction. We investigated the correlation between atherosclerosis and tissue and serum levels of endothelin-1 in patients with chronic kidney disease (CKD). MATERIALS AND METHODS. Arterial samples were obtained from 35 patients with CKD during arteriovenous fistula placement. Thirty-one patients with cardiovascular disease who underwent coronary artery bypass graft (CABG) were selected as the atherosclerotic group, and a piece of their aorta punched during CABG was obtained. Also, a small piece of the renal artery was dissected during donation in 24 kidney donors (control group). Tissue endothelin-1 level was measured and atherosclerosis grading was determined by pathologic examination. Serum levels of endothelin-1 were also measured in the three groups. Results. The mean tissue endothelin-1 levels were 10.73+/-7.57 pg/mL, 12.16 +/- 3.95 pg/mL, and 0.93 +/- 1.06 pg/mL in the patients with CKD, those with CABG, and donors, respectively (P < .001). The mean serum endothelin-1 level was 25.23 +/- 15.15 pg/mL in the patients with CKD, 21.13 +/- 17.22 pg/mL in the patients with CABG, and 2.66 +/- 1.51 pg/mL in the donors (P < .001). Atherosclerosis grades correlated with tissue endothelin-1 level (r = 0.823, P < .001) and serum endothelin-1 level (r = 0.608, P < .001) in the patients with CKD. Multiple regression analysis showed tissue endothelin-1 level as the main predicting factor of atherosclerosis (P < .001). CONCLUSIONS. Tissue endothelin-1 concentration is more important than serum endothelin-1 or lipids levels in prediction of atherosclerosis. Thus, blockade of tissue endothelin-1 receptors with its antagonists may prevent atherosclerosis progression.

Postnephrectomy changes in Doppler indexes of remnant kidney in unrelated kidney donors

INTRODUCTION

We aimed to evaluate the intralobar renal arteries indexes using the Doppler ultrasonography indexes, which have become the established method of kidney monitoring, in living unrelated kidney donors during the postnephrectomy period.

MATERIALS AND METHODS

In this prospective study, we evaluated and followed up 34 living unrelated kidney donors. The Doppler ultrasonography indexes, including resistive index, pulsatility index, and peak systolic velocity, along with the grey-scale ultrasonographic indexes of cortical thickness, length, and anteroposterior diameter of the kidney were determined before nephrectomy, and then, 1 week and 3 months after nephrectomy. In addition, glomerular filtration rate were assessed simultaneously.

RESULTS

The resistive index and pulsatility index did not change 1 week and 3 months after nephrectomy (P = .66 and P = .38, respectively). The peak systolic velocity at 1 week was significantly higher than its prenephrectomy value (P = .02). Also, the peak systolic velocity at 3 months was significantly higher than that prior to nephrectomy (P < .001). Indexes of the kidney size all increased during the follow-up period. The estimated glomerular filtration rate increased decreased 1 week after nephrectomy, but it reach to a level comparable with its preoperative values after 3 months.

CONCLUSION

Results of the present study showed an increased peak systolic velocity in association with unaltered resistive index and pulsatility index in the remnant kidney of donors, during the short-term follow-up. This finding indicates the increased blood flow and kidney size in the remnant kidney of donors, following nephrectomy.

Effect of diuretics on ureteral stone therapy with extracorporeal shock wave lithotripsy

To evaluate the effect of diuretics on ureteral stone fragmentation and clearance during therapy with extra corporeal shock wave lithotripsy (ESWL), we studied 87 patients with ureteral stone at different levels and treated with ESWL. The patients were randomized into two groups treated by standard ESWL; the treatment protocol included 3500 shock wave per patient in each session, energy of the shock in two groups was 13 to 9 kv per patient, and the number of sessions was 3 per patient. The first group included 43 patients who received only ESWL, while the second group of 44 patients received as well 40 mg of furosemide. Stone fragmentation rate was 81% and 93.1% and stone clearance rate was 68.2% and 88.4% for the first and the second groups, respectively. With diuretics, fragmentation was 18.8% more in the middle ureteral stones, 16.9% more in the upper tract stones, and 5.4% more in the distal stones. Moreover, clearance of fragmented stones was 38%, 28%, 15.4% more at middle and upper and distal ureteral stone, respectively. We conclude that the stone fragmentation and clearance were higher with ESWL and diuretics than without diuresis. Diuresis is safe and has some advantage at increasing the effect of ESWL on ureteral stones especially the middle ureteral calculi.

Viable testis after retroperitoneal mass cord ligation in internal ring of inguinal canal in 15 kidney recipients: five years of experience

INTRODUCTION

Sometimes in spermatic cord handling procedures like varicocelectomy, hernioraphy, and vasectomy, there is concern about perfusion of the testis. Herein we have presented our experience with retroperitoneal mass ligation of the cord in kidney recipients. Between 2001 and 2006, we performed mass ligation of the spermatic cord, including vas deferens and all spermatic vessels, in 15 kidney recipients (older than 55 years) who gave informed consent. During retroperitoneal preparation of the Iliac fossa for allografting, we performed this maneuver next to the internal ring of the inguinal canal. After performing a J incision in the right iliac fossa, separating fascia, and pushing the peritoneum medially, we isolated the spermatic cord at the internal ring of the inguinal canal for transfixation and placing the allografted kidney in retroperitoneal position with anastomoses of the iliac vessels. Posttransplantation the scrotum of patients was followed up by color Doppler ultrasound and physical examination.

RESULT

Normal circulation was detected in the testis postoperation using color Doppler ultrasound evaluation. Six patients returned with hydrocoeles between 4 and 8 months after transplantation and 3 of them underwent hydrocoelectomy.

CONCLUSION

Mass ligation of the spermatic cord (preinternal ring of inguinal canal) did not disturb the circulation to the testis severely nor did it induce ischemic problems (atrophy). This study suggested an unknown connection between vessels of the cord and other vessels that supply blood to the testis. This study questions the safety of cryo-biopsy of a testis mass by high clamping of the cord and also suggests that vasectomy may be safe in patients with a history of a standard Palomo varicocoelectomy.

Is antibiotic usage necessary after donor nephrectomy? A single center experience

Proper management of living kidney donors is a very important aspect of all renal transplants. To date, approximately 60,000 living donor nephrectomies have been performed worldwide and about 20 deaths directly related to the operation have been reported. The most common cause of death has been pulmonary embolism. Wound infection following surgery is the third most common nosocomial infection, and is dependent on the surgeon and his/her team, the operating room, number and virulence of contaminated bacteria, patient characteristics (immunity and defense), as well as time and duration of administration of antibiotics. Approach to the prophylaxis of wound infection in kidney donors varies in different transplant centers. This study was conducted at the Emam Hospital, Tabriz, Iran in order to delineate the protocol regarding antibiotic usage after donor nephrectomy. One hundred kidney donors were enrolled in the study. They were classified randomly in two groups: Group-1, comprising 50 donors, who received antibiotics immediately following surgery and for at least seven days thereafter. Group-2, comprised of 50 donors, in whom one gram of cephazoline was injected intravenously before anesthesia and continued for 24 hours after surgery. The patients were followed-up for one month with particular emphasis on occurrence of wound infection. One patient in Group-1, and two in Group-2 had wound infection; the difference was not statistically significant (p = > 0.5). Our study suggests that antibiotic prophylaxis started before incision and continued for 24 hours after donor nephrectomy is safe and effective in preventing wound infection.

Evaluation of blood flow in allograft renal arteries anastomosed with two different techniques

Renal artery stenosis in renal transplantation (TRAS) is an avoidable short or long-term surgical complication. The etiology is multifactorial, but faulty anastomosis is a major factor. In our transplant center, we evaluated the incidence of TRAS with the use of two different suturing techniques of the anastomosis site between the allograft renal and iliac arteries in two groups of renal transplant recipients, group A: 14 patients (6 males and 8 females with age 16 to 59 and mean age of 38 years) in whom the allograft arteries were anastomosed with a continuous suture technique, and group B: 14 patients (7 males and 7 females, with age 32 to 61 and mean age of 46.6 years) in whom the allograft arteries were anastomosed with a combined suture technique (continuous and interrupted). Post transplantation, the velocity of blood flow in the renal and iliac arteries at the site of anastomosis was measured by color Doppler ultrasound. The ultrasonographer was blinded to the surgical technique in both study groups. The ratio of the maximum velocity of blood at the site of anastomosis to that in the iliac artery of less than 2.5 was considered as non-significant stenosis, while a ratio of more than 2.5 was considered significant stenosis. In group A there were 9 cases of non-significant stenosis in comparison to 3 cases in group B, while there were no cases of significant stenosis in group A in comparison to 3 cases in group B; the difference was not statistically significant. We conclude that there was no difference in the incidence of stenosis in the compared surgical techniques of anastomosis in our study groups. This suggests that other factors such as gentle handling of tissue, enough spatula, margin reversion, and comparable diameter of the anastomosed vessels may be more important in the prevention of renal allograft stenosis than the type of suture technique.

Modified anterior abdominal donor nephrectomy in comparison with laparoscopic donor nephrectomy

Recently with introduction of laparoscopic nephrectomy, the procedure has become more appealing to living donors because of smaller laparoscopic incision and decreased length of hospital stay. However, because of the relatively prolonged warm ischemia time, increased operating time, and delayed graft function, the current laparoscopic donor nephrectomy is still subject to further development. We introduced a modified anterior abdomen incision for donor nephrectomy with advantages of laparoscopic procedure but with shorter warm ischemia and operation time. In 15 donors, a 10 cm incision was performed in the upper side of the abdomen between the rectus muscle and the tip of the ribs, while the donor was in flank position. Then, the kidney was exposed and freed followed by ureter nephrectomy. Afterwards, the abdominal wall was repaired without drain. The time of operation (from incision skin to suturing of skin) was from 1-1.5 hours with a few seconds of warm ischemia time. The donors experienced tolerable pain and all of them were discharged from hospital two days post operation. All grafts in recipients started to diurese immediately. Cosmetic appearance of wounds after operation and six months later were good. In conclusion, the modified anterior abdominal incision is safe and comparable with the conventional laparoscopic procedure in the size of the incision, the cosmetic appearance, the incision pain, and time of discharge. It may be advised as an alternative laparoscopic nephrectomy procedure.

Debulking transplant nephrectomy leaving an intact ureter and instillation of betadine intracapsular is safe nephrectomy: fifteen years' experience

BACKGROUND

Transplant nephrectomy has been reported to display a high morbidity (17% to 56%) and considerable mortality (13% to 14%). We used a debulking technique leaving an intact ureter with intracapsular instillation of betadine; it was associated with a low rate of complications.

MATERIALS AND METHODS

A total of 25 patients (16 males, 9 females) with failed allografted kidneys underwent transplant nephrectomy between 1991 and 2006 (Group 1). All subjects had failed kidneys for 2 months or more posttransplantation. The surgical approach to allograft nephrectomy was via the same oblique incision in the iliac fossa as the original transplantation. The capsule of the allograft was exposed and incised from pole to pole for the renal parenchyma to be bluntly dissected free with an index finger. The kidney parenchyma was pulled outward, and then the pedicle was ligated with silk, and layer by layer the tissue was removed until reaching the pedicle. Again it was transfixed and carefully ligated. After homeostasis, diluted betadine was instilled into the capsule and a drain inserted. The allograft ureter and capsule were left intact. All cases were followed for at least 1 year. Postnephrectomy, small doses of immunosuppressive drugs were continued for at least 2 months.

RESULTS

Intracapsular nephrectomy was not associated with a significant complication.

CONCLUSION

Intracapsular debulking nephrectomy, leaving the ureter and capsule intact and with intracapsular instillation of betadine, was a safe technique to remove a delayed, failed allograft.

Double urinary bladder voiding technique post removal of urethral catheter in renal allograft recipients

To evaluate the effect of urinary bladder double voiding technique on the incidence of urinary tract infection in the transplant patients with double J stents after the removal of the urethral catheters in the post-transplant period, we evaluated 65 recipients of live kidney transplant in whom we inserted double J stents and urethral catheters at the time of transplantation. After removing the urethral catheters on post-operation day six, we instructed a group of 30 patients to double void their bladders within five minutes after the first micturition. The rest of the patients served as controls. Urine cultures were repeated frequently before and at the time of removal of urethral catheters and double J stents to detect the incidence of urinary tract infection in both groups. All recipients received cotrimoxazol prophylactically. The group of patients who performed the double voiding technique had significantly lower incidence of positive urine cultures than the control group at the time of removing the double J stents (1 (3.3%) vs. 12 (34.2%) respectively). We conclude that double voiding may reduce risk of urine infection in patients with double J stents in renal allograft ureters.

Instillation of povidone iodine to treat lymphocele and leak of lymph after renal transplantation

Lymphoceles are common surgical complications of renal transplantation. Recently minimal invasive therapy has been advised. We studied the safety and efficacy of instillation of povidone iodine via transcutaneous catheter for treatment of lymphoceles and leaks of lymph. We studied 10 (four males, six females) kidney transplant recipients who developed lymphoceles after transplantation and four (three males, one female) who developed leaks of lymph. We treated these cases by povidone iodine after placement of transcutaneous catheters with guidance of ultrasound and confirmed the presence of lymph by biochemical analysis. After dilution of povidone iodine to 5% with normal saline, 20cc were instilled and dwelled in the cavity for 30 minute three times daily. The lymph was then allowed to drain by gravity. For the leaks of lymph, which occurred immediately post operation, the catheters were placed during transplantation surgery. All patients were followed up for four months. After one week of instillation, all lymph leaks were completely blocked. Furthermore, nine (90%) cases of lymphocele resolved after 15 days of therapy. We conclude that instillation of diluted povidone iodine for treatment of lymphocele and leak of lymph is safe and effective and it may be considered as first choice for these conditions.

New technique for allograft ureteroneocystomy for better transvesical endoscopic handling of allograft urological complications

We studied a new ureteroneocystostomy technique for the anastomosis of the transplanted ureter and the native bladder that involves the change of the position of the neoureteral orifice during renal graft transplantation to the posterio-lateral aspect of the bladder's dome. We applied the technique on 30 consecutive renal transplant recipients (25 males and five females with ages between 15-50 years). Mucosa to mucosa anastomosis was performed, and all of the patients had double J (DJ) stents inserted in the ureters. The patients were followed for one year. At the time of removing the DJ stents, we evaluated the ureters by inserting ureteral catheters and by performing ureteroscopy transvesically and the results were compared with another group of 30 patients who underwent the conventional anterio-lateral ureteroneocystostomy. The retrograde stenting of the ureters was much more easily performed in the study group than the controls. During the follow-up of the study patients, renal ultrasound and renal function tests did not disclose any urological complications. We conclude that the new technique is effective and safe and enabled better retrograde handling of the allograft ureter than the conventional ureteroneo-cystostomy. Advantages of the new technique included the need for a shorter ureter, the normally appearing orifice of the allograft ureter in the bladder, and the unproblematic retrograde vesical approach for the posterolateral ureter.

Comparison of the effect of body position, prone or supine, on the result of extracorpreal shock wave lithotripsy in patients with stones in the proximal ureter

The aim of this study was to determine whether positioning of the patient, prone or supine, plays a significant role on the treatment of stones in the proximal ureter with extracorporeal shock wave lithotripsy (ESWL). 68 patients with proximal ureteric stones underwent ESWL. The procedure was performed in the supine position in 35 (Group 1) and the prone position in 33 patients (Group 2). Stone-free rates, repeat ESWL rates, shocks per patient and shocks per session were compared in both groups. The mean session number per patient was 1.93 +/- 0.82 in Group 1 and 1.88 +/- 0.79 in Group 2 (P = 0.786). The stone-free rates, three months after ESWL, were 81.8% in Group 1 and 82.9% in Group 2 (P = or > 0.05). Thus, these two parameters were similar in both Groups. Also, the number of shocks per session was 3066.1 +/- 346.3 in Group 1 and 3148.5 +/- 621.0 in Group 2. This difference was nonsignificant (P = 0.49). Our study suggests that the treatment of proximal ureteric stones with ESWL in the prone position is as safe and effective as when the patient is placed in the supine position.

Extracorporeal shock wave lithotripsy in prone and supine positions for patients with upper ureteral calculi

INTRODUCTION

The aim of this study was to evaluate the treatment of upper ureteral calculi with extracorporeal shock wave lithotripsy (SWL) in the supine and prone positions.

MATERIALS AND METHODS

A total of 68 patients with upper ureteral calculi underwent SWL. In 35 patients, the procedure was performed in the supine position (group 1), while in the 33 remainders, it was performed in the prone position (group 2). The stone-free rate, the number of SWL sessions required, and the number of shocks per treatment session were compared between the 2 groups.

RESULTS

The mean calculus size was 12.4 +/- 3.1 mm and 12.2 +/- 2.9 mm in groups 1 and 2, respectively. The stone-free rate was 81.8% in group 1 and 82.9% in group 2 (P = .91). The number of sessions for achieving the stone-free status was similar in the patients of the 2 groups (1.9 +/- 0.8 in group 1 versus 1.9 +/- 0.8 in group 2; P = .79). The mean number of shock waves per treatment session was not significantly different between the 2 groups. No major complications were seen and none of the patients required hospitalization, placement of a ureteral catheter, or a double-J stent.

CONCLUSION

Our study showed that in the prone position, treatment of the upper ureteral calculi by SWL is as safe and effective as the supine position.