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.