a United States Army Medical Department
continuing education program,
Technical problems.
Urologic with john
Szaniawski,
Major U.S.
Air Force Medical Corps Staff urologist
Wilford Hall U.S.
Air Force Medical Center.
Lackland Air Force Base
at the present time.
An increasing percentage of patients with
neurologic abnormalities are undergoing
transplantation.
And I would like to convey some suggestions to you for
the pre transplantation evaluation and
preparation of these patients.
From a urologist viewpoint,
This slide summarizes our experience at Wilford Hall.
Over the last 17 months of the 28
transplantations performed 12 or
slightly more than 40% have been in patients
with underlying neurologic abnormalities.
The various types of problems are listed here.
The largest group of patients were those with reflux
and in fact half of our patients had reflux
because the patient listed as
myelodysplasia.
And this one with prune belly syndrome also had
this condition.
I don't know how well this projects but this however,
is a sista gram from one of the patients who is not known to
reflux.
This is from his routine pre transplant
evaluation.
He had denied any previous symptom Atala Ji.
And when I saw this X ray,
I asked him and he agreed that he had had
pain in his flank with boarding.
In fact,
he'd had it for as long as he could remember And
at age 17 he'd call this to a
physician's attention.
The doctor examined him,
did a urine analysis and told him that everything was
all right now,
reflux is important in two respects.
First,
the process can cause renal damage and
destruction even in the absence of
infection.
It is an abnormal phenomenon in humans
and I believe should be looked for
evaluated and treated when discovered.
If the patient whose film you see had undergone
a re implant,
his transmitter may have been delayed or
even unnecessary.
That's a little crusading.
But reflux is important to us because the
residual urine which is continuously present,
predisposes to infection.
And of course any such tendency must be obviated prior
to transplantation.
Therefore the presence of Mexico,
your federal or vesicular renal reflux is
an indication for pre transplant and a friend to me.
This is mandatory if the patient has previously
undergone a superb bicycle diversion that
is either in a frost to me or a cutaneous
yuri Harasta me,
the ureter must be removed to the bladder
but this does not have to be done in the same
sitting.
Let me illustrate the slide,
I'm about to show you is a sista gram from a young
patient that we had who was known to have
bilateral reflux.
He had extensive upper tract damage and for that
reason after an initial diversion which
consisted of bilateral loop cutaneous rita
Rostam,
ease.
No further reconstructive surgery was deemed feasible
and the important point of the study which you are about to
see is that despite the continued presence
of reflux,
this patient's bladder was still
usable.
It was a functionally normal organ
and emptied completely.
Now,
one month prior to his transplantation date
we performed bilateral mastectomies on this
patient and we removed his proximal ureter.
We also excised his Eureka Rostami
sites and removed as much of the distal
ureter as possible,
litigating the remaining stumps.
We then removed his distal ureter at the time of
transplantation.
This is the cyst a gram from the first patient I think
you can see the reflux of his ureter is this is the approximate
site of his cutaneous.
Read a rasta me on this side.
Same finding on this side.
But this is his post op post voiding film on
his sister Graham.
You can see that he really empties his bladder completely.
You can still see a wisp of die in
his ureter on this side.
This shows his transplant in place
following that patient.
I would like to discuss with you another
patient who also was a youngster who
had a non functioning kidney with
reflux on one side and a hydro
frantic and diminished functioning kidney on the other.
He also necessitated preoperative affect
amis and additionally
had a bladder neck contracture upon evaluation.
Now at the time of his surgery we performed a
trans urethral resection of his bladder neck
and left a super pubic cyst Ostuni tube indwelling
because his bladder had been d functional.
Ized that is there was no urine entering the bladder.
His bladder capacity increased and he was
able to empty his bladder completely.
The super pubic cyst Ostuni two was
removed approximately two weeks prior to his
transplantation and the tract healed
completely.
His bladder readily accepted a re
implantation at the time of his transplant.
In his functioning fine sense,
this is the next lad that I discussed.
He's got reflux from his bladder into this
kidney which was non functioning.
I don't think you can appreciate it.
But on endoscopy here we know that a marked
contractor of his vesicles neck.
This is a study through his end cutaneous rita
rasta me of his right kidney,
which was still working but eventually ran out of gas.
And this is a postoperative study.
You can see this bladder neck is now wide open,
there's no reflux present.
He emptied this bladder completely and we were able to use it
at the time of transplantation.
Now the foregoing two examples emphasize the
fact that bladders and certain patients
who have previously required urinary diversions
for their urologic problems may be
functional organs and thus may be
usable in transplantation.
Often relatively straightforward measures or
simple urologic procedures can
rehabilitate the recipient
bladder.
I also feel that patients awaiting cadaveric
transplants should have their bladder status
assessed periodically,
at least annually because patients with
minimal urine output or those who have had
previous affect.
Amis can develop diminished bladder
capacities insidiously and re
implantation into a small contracted bladder
is fraught with technical hazards and the
results can be disastrous.
This slide is a cyst.
A gram of one of our chronic dialysis patients.
She would only hold 100 CCs of europe as a
result of her previous D functional ization.
When her own kidneys were removed and her initial
transplant had to be removed.
She had been on dialysis for approximately two year
period of time.
This is avoiding film,
I think you may have noticed on the other film as well as on this one,
she has reflux into her own.
Your literal stump.
We instituted a program of hydro dilatation
of this patient's bladder by instilling
a foley catheter weekly,
filling her with jamison solution
placed under gravity at 40 centimeters of
water height and over a three month
period she increased her bladder capacity to
225 CCs and this
enabled us to use her bladder for a
re implant.
At the time of transplantation.
May I have the slides off,
please.
A normally functioning bladder is far superior
to any type of urinary diversion as a
receptacle for urine and a renal transplant,
not only in terms of social convenience,
but more importantly,
in terms of Obviating any infectious tendency
which could destroy the graft.
But this is not to say that kidneys cannot be
transplanted into various types of urinary
diversions.
Such maneuvers are necessary when the bladder cannot
be rehabilitated or in cases of neurogenesis
vesicles dysfunction,
I do not have a slide to show you of either of the two
patients in which we have transplanted during the last year
and a half into illegal conduits,
but such intestinal diversion certainly can be used.
They,
however,
must be constructed prior to transplantation.
If you're in a role,
illegal anastomosis is watertight
is large enough.
And Qingqing of either the ureter or the
illegal conduit are avoided.
Then we should really have few difficulties from these
patients.
Our patients had their kidneys placed intra abdominal E
but in certain situations retro peritoneal kidney
positioning would be feasible.
Now as older patients are being accepted for
transplantation,
Men with prostatic hypertrophy will be
encountered.
The importance of the pre transplantation evaluation
to include Sista Skopje when indicated
cannot be underestimated.
May I have the slides please.
This is avoiding sister urethra Gram from a 43
year old chronic renal failure patient.
I think you can appreciate that.
He's got a very narrow prostatic urethra.
He had a residual urine volume of over
100 CCs.
He underwent a trans urethral
resection and I think you can note the
improvement in the caliber of his prostatic urethra.
He was able to empty his bladder completely
and we were able to perform his transplantation.
I believe that the time for reconstructive surgery
is prior to transplantation,
patients in renal failure are not ideal surgical
candidates.
But patients on immuno suppression are less so
enabling a patient to empty his bladder will
obviate the necessity of long term catheterization,
post transplantation and lessen the likelihood
of urinary infection and especially chronic
prostatitis.
I'd like to make a few points regarding trans urethral
surgery in these patients.
I'm sure there are not many urologists in the audience
but perhaps you can convey these to your consultants when you
return to your respective institutions.
The preoperative evaluation of these patients must be
as thorough as for transplantation,
especially in regard to the patient's hematologist and
clotting status.
Homeostasis inter operatively must be meticulous.
These patients simply do not stop bleeding.
Like a normal prostatectomy patient.
Would I leave a three way catheter
indwelling following prostatectomy so
that I can supplement the patient's own urine output which
may be low with ice osmotic irrigation.
The catheter is not removed until the
drainage of only the patient's urine has been
clear and he is fully ambulance now.
This is usually somewhat longer than in the usual
prostatectomy patient but has not exceeded
seven days.
The college area which is present,
may contribute to a tendency of bladder
neck contracture.
After prostatectomy.
This occurred in one of our patients but was readily remedied
by a repeat resection and the
reception should ideally be accomplished approximately
six weeks prior to the intended date of
transplant because this will allow complete
healing of the prostatic fossil prior to that time.
Now polycystic kidney disease as has been mentioned,
is also an indication for preoperative affect to
me because of the complications of bleeding and infection
because we're here in texas and texas.
Everything is bigger than anywhere else.
I thought you might enjoy seeing this next case.
This is active duty Lieutenant colonel who was transferred
to us because he was septic from infected
kidneys.
This is a retrograde study.
I think you can see a large kidney on the left side.
This is an arteriogram,
arteriogram of his right kidney
and an arteriogram of his left kidney.
And you can see that the contrast from
the retrograde study which was done the preceding
day is still present.
This kidney was draining very poorly.
In addition,
because of its large size,
it was actually causing colonic obstruction.
This patient was taken to surgery and this is a picture of his
kidney at the time of operation.
This was removed and his symptoms were cured.
This shows his kidney and relationship to a normal sized
kidney model.
This kidney was approximately 32 cm in length.
Patients with malignancies such as Wilms,
tumors or adenocarcinoma of the kidney or
transitional cell carcinoma of the kidney can
also be candidates for transplantation after
an appropriate metastasis.
Free period has been documented.
We have one such patient in our series who proved to be an
interesting technical challenge,
but her outcome has been very satisfying to all of those
who have taken care of her.
In summary.
I expect patients with neurologic abnormalities to
constitute an increasing percentage of
patients undergoing transplantation.
The importance of a thorough preoperative
urologic investigation has been emphasized
While reflux is an indication for pre
transplant nephrology.
Redirect ammi reconstructive surgery
can often provide a functional bladder in
patients who have previously needed a
urinary diversion.
When this is unfeasible
transplantation into intestinal conduits is
necessary.
Older male patients can have significant prostatic
hypertrophy and I've made some suggestions for
pre transplantation too.
You are in these patients.
Technical problems.
Urologic with john
Szaniawski,
Major U.
S.
Air Force Medical Corps Staff Urologist
Wilford Hall U.
S.
Air Force Medical Center,
Lackland Air Force Base
was produced through the mobile facilities of the Television
division,
Academy of Health Sciences,
United States Army Fort SAm Houston
texas.