WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:13.840 --> 00:16.250 a United States Army Medical Department 00:16.250 --> 00:18.340 continuing education program, 00:19.370 --> 00:20.690 Technical problems. 00:20.700 --> 00:23.400 Urologic with john 00:23.400 --> 00:24.120 Szaniawski, 00:24.120 --> 00:24.760 Major U.S. 00:24.920 --> 00:27.760 Air Force Medical Corps Staff urologist 00:27.760 --> 00:28.600 Wilford Hall U.S. 00:28.770 --> 00:30.140 Air Force Medical Center. 00:30.150 --> 00:31.610 Lackland Air Force Base 00:34.390 --> 00:35.450 at the present time. 00:35.450 --> 00:38.080 An increasing percentage of patients with 00:38.090 --> 00:41.040 neurologic abnormalities are undergoing 00:41.040 --> 00:42.060 transplantation. 00:43.020 --> 00:46.000 And I would like to convey some suggestions to you for 00:46.000 --> 00:48.780 the pre transplantation evaluation and 00:48.780 --> 00:50.490 preparation of these patients. 00:50.500 --> 00:52.710 From a urologist viewpoint, 00:55.490 --> 00:58.090 This slide summarizes our experience at Wilford Hall. 00:58.090 --> 01:00.980 Over the last 17 months of the 28 01:00.980 --> 01:03.730 transplantations performed 12 or 01:03.730 --> 01:06.700 slightly more than 40% have been in patients 01:06.700 --> 01:09.060 with underlying neurologic abnormalities. 01:10.490 --> 01:12.970 The various types of problems are listed here. 01:14.800 --> 01:17.740 The largest group of patients were those with reflux 01:17.770 --> 01:20.360 and in fact half of our patients had reflux 01:20.360 --> 01:22.170 because the patient listed as 01:22.170 --> 01:23.680 myelodysplasia. 01:23.710 --> 01:26.550 And this one with prune belly syndrome also had 01:26.550 --> 01:27.310 this condition. 01:31.370 --> 01:33.870 I don't know how well this projects but this however, 01:33.870 --> 01:36.670 is a sista gram from one of the patients who is not known to 01:36.670 --> 01:37.340 reflux. 01:37.650 --> 01:40.120 This is from his routine pre transplant 01:40.430 --> 01:41.630 evaluation. 01:42.220 --> 01:44.690 He had denied any previous symptom Atala Ji. 01:44.690 --> 01:46.130 And when I saw this X ray, 01:46.300 --> 01:49.260 I asked him and he agreed that he had had 01:49.270 --> 01:50.790 pain in his flank with boarding. 01:51.170 --> 01:51.710 In fact, 01:51.710 --> 01:54.630 he'd had it for as long as he could remember And 01:54.630 --> 01:57.070 at age 17 he'd call this to a 01:57.070 --> 01:58.190 physician's attention. 02:00.210 --> 02:02.070 The doctor examined him, 02:02.280 --> 02:05.140 did a urine analysis and told him that everything was 02:05.140 --> 02:07.020 all right now, 02:07.020 --> 02:09.680 reflux is important in two respects. 02:09.690 --> 02:11.140 First, 02:11.150 --> 02:13.930 the process can cause renal damage and 02:13.930 --> 02:16.410 destruction even in the absence of 02:16.410 --> 02:17.110 infection. 02:18.490 --> 02:21.410 It is an abnormal phenomenon in humans 02:21.420 --> 02:24.030 and I believe should be looked for 02:24.040 --> 02:26.850 evaluated and treated when discovered. 02:27.690 --> 02:30.690 If the patient whose film you see had undergone 02:30.690 --> 02:31.550 a re implant, 02:31.560 --> 02:34.440 his transmitter may have been delayed or 02:34.440 --> 02:35.700 even unnecessary. 02:36.760 --> 02:38.450 That's a little crusading. 02:38.460 --> 02:41.460 But reflux is important to us because the 02:41.460 --> 02:44.280 residual urine which is continuously present, 02:44.290 --> 02:46.410 predisposes to infection. 02:47.120 --> 02:50.080 And of course any such tendency must be obviated prior 02:50.080 --> 02:51.220 to transplantation. 02:52.000 --> 02:54.310 Therefore the presence of Mexico, 02:54.620 --> 02:57.600 your federal or vesicular renal reflux is 02:57.600 --> 03:00.330 an indication for pre transplant and a friend to me. 03:01.610 --> 03:04.500 This is mandatory if the patient has previously 03:04.500 --> 03:07.410 undergone a superb bicycle diversion that 03:07.410 --> 03:10.340 is either in a frost to me or a cutaneous 03:10.340 --> 03:11.330 yuri Harasta me, 03:13.160 --> 03:15.810 the ureter must be removed to the bladder 03:16.520 --> 03:19.310 but this does not have to be done in the same 03:19.310 --> 03:19.770 sitting. 03:20.680 --> 03:23.230 Let me illustrate the slide, 03:23.230 --> 03:26.110 I'm about to show you is a sista gram from a young 03:26.110 --> 03:28.820 patient that we had who was known to have 03:28.820 --> 03:30.150 bilateral reflux. 03:30.450 --> 03:33.080 He had extensive upper tract damage and for that 03:33.080 --> 03:35.650 reason after an initial diversion which 03:35.650 --> 03:38.270 consisted of bilateral loop cutaneous rita 03:38.270 --> 03:38.730 Rostam, 03:38.730 --> 03:39.040 ease. 03:39.830 --> 03:42.750 No further reconstructive surgery was deemed feasible 03:43.380 --> 03:46.040 and the important point of the study which you are about to 03:46.040 --> 03:48.960 see is that despite the continued presence 03:48.960 --> 03:50.090 of reflux, 03:50.130 --> 03:52.480 this patient's bladder was still 03:52.480 --> 03:53.270 usable. 03:53.280 --> 03:55.700 It was a functionally normal organ 03:55.710 --> 03:57.910 and emptied completely. 03:58.730 --> 03:59.030 Now, 03:59.030 --> 04:01.980 one month prior to his transplantation date 04:02.060 --> 04:04.790 we performed bilateral mastectomies on this 04:04.790 --> 04:07.620 patient and we removed his proximal ureter. 04:07.940 --> 04:10.440 We also excised his Eureka Rostami 04:10.440 --> 04:13.230 sites and removed as much of the distal 04:13.230 --> 04:15.020 ureter as possible, 04:15.310 --> 04:17.290 litigating the remaining stumps. 04:18.930 --> 04:21.730 We then removed his distal ureter at the time of 04:21.730 --> 04:22.760 transplantation. 04:25.050 --> 04:28.030 This is the cyst a gram from the first patient I think 04:28.030 --> 04:30.980 you can see the reflux of his ureter is this is the approximate 04:30.980 --> 04:32.050 site of his cutaneous. 04:32.050 --> 04:33.450 Read a rasta me on this side. 04:33.810 --> 04:35.270 Same finding on this side. 04:36.030 --> 04:38.970 But this is his post op post voiding film on 04:38.970 --> 04:39.720 his sister Graham. 04:39.720 --> 04:41.870 You can see that he really empties his bladder completely. 04:41.870 --> 04:44.540 You can still see a wisp of die in 04:44.550 --> 04:46.230 his ureter on this side. 04:48.930 --> 04:51.180 This shows his transplant in place 04:52.660 --> 04:54.660 following that patient. 04:54.670 --> 04:57.220 I would like to discuss with you another 04:57.220 --> 05:00.090 patient who also was a youngster who 05:00.090 --> 05:02.930 had a non functioning kidney with 05:02.930 --> 05:05.440 reflux on one side and a hydro 05:05.440 --> 05:08.200 frantic and diminished functioning kidney on the other. 05:10.490 --> 05:13.240 He also necessitated preoperative affect 05:13.240 --> 05:15.920 amis and additionally 05:16.400 --> 05:18.940 had a bladder neck contracture upon evaluation. 05:20.000 --> 05:22.860 Now at the time of his surgery we performed a 05:22.860 --> 05:25.680 trans urethral resection of his bladder neck 05:26.470 --> 05:29.390 and left a super pubic cyst Ostuni tube indwelling 05:29.630 --> 05:31.880 because his bladder had been d functional. 05:31.880 --> 05:34.770 Ized that is there was no urine entering the bladder. 05:36.100 --> 05:38.870 His bladder capacity increased and he was 05:38.880 --> 05:40.740 able to empty his bladder completely. 05:41.920 --> 05:44.640 The super pubic cyst Ostuni two was 05:44.640 --> 05:47.110 removed approximately two weeks prior to his 05:47.110 --> 05:49.810 transplantation and the tract healed 05:49.820 --> 05:50.610 completely. 05:51.330 --> 05:53.610 His bladder readily accepted a re 05:53.610 --> 05:55.850 implantation at the time of his transplant. 05:56.120 --> 05:58.260 In his functioning fine sense, 05:59.390 --> 06:01.320 this is the next lad that I discussed. 06:01.320 --> 06:03.790 He's got reflux from his bladder into this 06:03.790 --> 06:06.110 kidney which was non functioning. 06:07.550 --> 06:08.880 I don't think you can appreciate it. 06:08.890 --> 06:11.130 But on endoscopy here we know that a marked 06:12.150 --> 06:13.920 contractor of his vesicles neck. 06:15.480 --> 06:18.450 This is a study through his end cutaneous rita 06:18.450 --> 06:20.530 rasta me of his right kidney, 06:20.530 --> 06:23.460 which was still working but eventually ran out of gas. 06:26.580 --> 06:28.390 And this is a postoperative study. 06:28.390 --> 06:30.710 You can see this bladder neck is now wide open, 06:31.100 --> 06:32.430 there's no reflux present. 06:32.490 --> 06:35.070 He emptied this bladder completely and we were able to use it 06:35.540 --> 06:36.970 at the time of transplantation. 06:40.260 --> 06:43.090 Now the foregoing two examples emphasize the 06:43.090 --> 06:45.870 fact that bladders and certain patients 06:45.880 --> 06:48.820 who have previously required urinary diversions 06:48.830 --> 06:51.410 for their urologic problems may be 06:51.410 --> 06:54.240 functional organs and thus may be 06:54.250 --> 06:56.130 usable in transplantation. 06:56.860 --> 06:59.780 Often relatively straightforward measures or 06:59.780 --> 07:02.330 simple urologic procedures can 07:02.330 --> 07:05.140 rehabilitate the recipient 07:05.140 --> 07:05.550 bladder. 07:06.620 --> 07:09.150 I also feel that patients awaiting cadaveric 07:09.160 --> 07:11.890 transplants should have their bladder status 07:11.900 --> 07:13.250 assessed periodically, 07:13.740 --> 07:16.730 at least annually because patients with 07:16.730 --> 07:19.430 minimal urine output or those who have had 07:19.430 --> 07:20.330 previous affect. 07:20.330 --> 07:23.120 Amis can develop diminished bladder 07:23.120 --> 07:25.970 capacities insidiously and re 07:25.970 --> 07:28.850 implantation into a small contracted bladder 07:29.270 --> 07:31.880 is fraught with technical hazards and the 07:31.880 --> 07:33.570 results can be disastrous. 07:34.410 --> 07:35.440 This slide is a cyst. 07:35.440 --> 07:37.850 A gram of one of our chronic dialysis patients. 07:37.890 --> 07:40.800 She would only hold 100 CCs of europe as a 07:40.800 --> 07:42.950 result of her previous D functional ization. 07:43.040 --> 07:45.760 When her own kidneys were removed and her initial 07:45.760 --> 07:47.460 transplant had to be removed. 07:48.080 --> 07:50.960 She had been on dialysis for approximately two year 07:50.960 --> 07:51.920 period of time. 07:53.350 --> 07:54.580 This is avoiding film, 07:54.770 --> 07:57.500 I think you may have noticed on the other film as well as on this one, 07:57.710 --> 07:59.310 she has reflux into her own. 07:59.310 --> 08:00.290 Your literal stump. 08:01.080 --> 08:03.960 We instituted a program of hydro dilatation 08:03.970 --> 08:06.940 of this patient's bladder by instilling 08:06.940 --> 08:08.360 a foley catheter weekly, 08:08.690 --> 08:11.100 filling her with jamison solution 08:11.250 --> 08:14.120 placed under gravity at 40 centimeters of 08:14.120 --> 08:16.400 water height and over a three month 08:16.410 --> 08:19.040 period she increased her bladder capacity to 08:19.040 --> 08:21.840 225 CCs and this 08:21.840 --> 08:24.760 enabled us to use her bladder for a 08:24.760 --> 08:25.350 re implant. 08:25.350 --> 08:26.820 At the time of transplantation. 08:27.780 --> 08:28.790 May I have the slides off, 08:28.790 --> 08:29.210 please. 08:30.280 --> 08:33.250 A normally functioning bladder is far superior 08:33.250 --> 08:35.760 to any type of urinary diversion as a 08:35.760 --> 08:38.140 receptacle for urine and a renal transplant, 08:38.610 --> 08:40.770 not only in terms of social convenience, 08:41.020 --> 08:42.040 but more importantly, 08:42.040 --> 08:44.680 in terms of Obviating any infectious tendency 08:44.820 --> 08:46.490 which could destroy the graft. 08:47.100 --> 08:49.420 But this is not to say that kidneys cannot be 08:49.420 --> 08:51.710 transplanted into various types of urinary 08:51.710 --> 08:52.480 diversions. 08:53.110 --> 08:55.960 Such maneuvers are necessary when the bladder cannot 08:55.960 --> 08:58.770 be rehabilitated or in cases of neurogenesis 08:58.770 --> 08:59.850 vesicles dysfunction, 09:00.680 --> 09:03.360 I do not have a slide to show you of either of the two 09:03.360 --> 09:06.290 patients in which we have transplanted during the last year 09:06.290 --> 09:08.190 and a half into illegal conduits, 09:09.230 --> 09:12.200 but such intestinal diversion certainly can be used. 09:12.610 --> 09:12.840 They, 09:12.840 --> 09:13.260 however, 09:13.260 --> 09:15.880 must be constructed prior to transplantation. 09:16.820 --> 09:17.830 If you're in a role, 09:18.720 --> 09:21.050 illegal anastomosis is watertight 09:21.900 --> 09:23.290 is large enough. 09:23.720 --> 09:26.410 And Qingqing of either the ureter or the 09:26.410 --> 09:28.120 illegal conduit are avoided. 09:28.650 --> 09:31.260 Then we should really have few difficulties from these 09:31.260 --> 09:31.870 patients. 09:32.680 --> 09:35.660 Our patients had their kidneys placed intra abdominal E 09:36.190 --> 09:39.000 but in certain situations retro peritoneal kidney 09:39.010 --> 09:40.530 positioning would be feasible. 09:42.110 --> 09:44.250 Now as older patients are being accepted for 09:44.250 --> 09:45.320 transplantation, 09:45.780 --> 09:48.390 Men with prostatic hypertrophy will be 09:48.390 --> 09:48.960 encountered. 09:49.880 --> 09:52.820 The importance of the pre transplantation evaluation 09:53.270 --> 09:55.460 to include Sista Skopje when indicated 09:55.650 --> 09:57.190 cannot be underestimated. 09:57.830 --> 09:59.130 May I have the slides please. 10:05.570 --> 10:08.470 This is avoiding sister urethra Gram from a 43 10:08.470 --> 10:10.960 year old chronic renal failure patient. 10:11.090 --> 10:12.470 I think you can appreciate that. 10:12.470 --> 10:14.790 He's got a very narrow prostatic urethra. 10:14.930 --> 10:17.660 He had a residual urine volume of over 10:17.660 --> 10:18.980 100 CCs. 10:19.140 --> 10:21.490 He underwent a trans urethral 10:21.490 --> 10:24.380 resection and I think you can note the 10:24.380 --> 10:27.060 improvement in the caliber of his prostatic urethra. 10:27.210 --> 10:29.670 He was able to empty his bladder completely 10:30.130 --> 10:32.380 and we were able to perform his transplantation. 10:33.480 --> 10:36.200 I believe that the time for reconstructive surgery 10:36.460 --> 10:38.420 is prior to transplantation, 10:39.190 --> 10:41.860 patients in renal failure are not ideal surgical 10:41.860 --> 10:42.650 candidates. 10:43.010 --> 10:45.720 But patients on immuno suppression are less so 10:49.730 --> 10:52.680 enabling a patient to empty his bladder will 10:52.680 --> 10:55.610 obviate the necessity of long term catheterization, 10:55.610 --> 10:58.610 post transplantation and lessen the likelihood 10:58.610 --> 11:01.370 of urinary infection and especially chronic 11:01.370 --> 11:02.310 prostatitis. 11:03.010 --> 11:05.920 I'd like to make a few points regarding trans urethral 11:05.920 --> 11:07.240 surgery in these patients. 11:07.600 --> 11:10.330 I'm sure there are not many urologists in the audience 11:10.620 --> 11:13.440 but perhaps you can convey these to your consultants when you 11:13.440 --> 11:15.960 return to your respective institutions. 11:16.850 --> 11:19.700 The preoperative evaluation of these patients must be 11:19.700 --> 11:21.700 as thorough as for transplantation, 11:21.840 --> 11:24.840 especially in regard to the patient's hematologist and 11:24.840 --> 11:25.880 clotting status. 11:26.700 --> 11:29.480 Homeostasis inter operatively must be meticulous. 11:29.940 --> 11:32.360 These patients simply do not stop bleeding. 11:32.570 --> 11:34.470 Like a normal prostatectomy patient. 11:34.470 --> 11:37.290 Would I leave a three way catheter 11:37.290 --> 11:40.230 indwelling following prostatectomy so 11:40.230 --> 11:43.210 that I can supplement the patient's own urine output which 11:43.210 --> 11:46.100 may be low with ice osmotic irrigation. 11:47.160 --> 11:50.070 The catheter is not removed until the 11:50.070 --> 11:52.690 drainage of only the patient's urine has been 11:52.690 --> 11:55.320 clear and he is fully ambulance now. 11:55.320 --> 11:57.840 This is usually somewhat longer than in the usual 11:57.840 --> 12:00.550 prostatectomy patient but has not exceeded 12:00.550 --> 12:01.540 seven days. 12:02.730 --> 12:04.550 The college area which is present, 12:04.550 --> 12:07.380 may contribute to a tendency of bladder 12:07.380 --> 12:08.670 neck contracture. 12:08.680 --> 12:10.160 After prostatectomy. 12:10.330 --> 12:13.330 This occurred in one of our patients but was readily remedied 12:13.380 --> 12:16.220 by a repeat resection and the 12:16.220 --> 12:19.070 reception should ideally be accomplished approximately 12:19.070 --> 12:21.610 six weeks prior to the intended date of 12:21.610 --> 12:24.540 transplant because this will allow complete 12:24.540 --> 12:27.220 healing of the prostatic fossil prior to that time. 12:28.830 --> 12:31.570 Now polycystic kidney disease as has been mentioned, 12:31.570 --> 12:34.540 is also an indication for preoperative affect to 12:34.540 --> 12:37.530 me because of the complications of bleeding and infection 12:38.100 --> 12:40.320 because we're here in texas and texas. 12:40.630 --> 12:42.590 Everything is bigger than anywhere else. 12:42.590 --> 12:44.820 I thought you might enjoy seeing this next case. 12:45.610 --> 12:48.590 This is active duty Lieutenant colonel who was transferred 12:48.590 --> 12:51.470 to us because he was septic from infected 12:51.930 --> 12:52.980 kidneys. 12:52.990 --> 12:54.450 This is a retrograde study. 12:54.450 --> 12:56.990 I think you can see a large kidney on the left side. 12:57.730 --> 12:59.390 This is an arteriogram, 13:01.370 --> 13:03.280 arteriogram of his right kidney 13:04.650 --> 13:06.350 and an arteriogram of his left kidney. 13:06.350 --> 13:08.770 And you can see that the contrast from 13:09.010 --> 13:11.790 the retrograde study which was done the preceding 13:11.790 --> 13:12.890 day is still present. 13:12.890 --> 13:14.630 This kidney was draining very poorly. 13:15.290 --> 13:15.830 In addition, 13:15.830 --> 13:17.380 because of its large size, 13:17.380 --> 13:19.650 it was actually causing colonic obstruction. 13:20.830 --> 13:23.670 This patient was taken to surgery and this is a picture of his 13:23.670 --> 13:25.310 kidney at the time of operation. 13:25.750 --> 13:28.430 This was removed and his symptoms were cured. 13:30.050 --> 13:33.010 This shows his kidney and relationship to a normal sized 13:33.020 --> 13:33.790 kidney model. 13:33.800 --> 13:36.590 This kidney was approximately 32 cm in length. 13:38.560 --> 13:40.970 Patients with malignancies such as Wilms, 13:40.970 --> 13:43.380 tumors or adenocarcinoma of the kidney or 13:43.380 --> 13:46.060 transitional cell carcinoma of the kidney can 13:46.060 --> 13:49.060 also be candidates for transplantation after 13:49.060 --> 13:50.480 an appropriate metastasis. 13:50.480 --> 13:52.600 Free period has been documented. 13:53.250 --> 13:56.090 We have one such patient in our series who proved to be an 13:56.090 --> 13:57.850 interesting technical challenge, 13:58.040 --> 14:01.020 but her outcome has been very satisfying to all of those 14:01.020 --> 14:02.320 who have taken care of her. 14:03.970 --> 14:05.220 In summary. 14:05.230 --> 14:08.150 I expect patients with neurologic abnormalities to 14:08.150 --> 14:10.800 constitute an increasing percentage of 14:10.800 --> 14:12.880 patients undergoing transplantation. 14:13.640 --> 14:16.080 The importance of a thorough preoperative 14:16.280 --> 14:18.990 urologic investigation has been emphasized 14:19.690 --> 14:22.180 While reflux is an indication for pre 14:22.180 --> 14:23.360 transplant nephrology. 14:23.440 --> 14:26.280 Redirect ammi reconstructive surgery 14:26.280 --> 14:29.080 can often provide a functional bladder in 14:29.080 --> 14:31.850 patients who have previously needed a 14:31.860 --> 14:33.190 urinary diversion. 14:34.100 --> 14:35.760 When this is unfeasible 14:36.160 --> 14:39.090 transplantation into intestinal conduits is 14:39.090 --> 14:39.870 necessary. 14:40.630 --> 14:43.460 Older male patients can have significant prostatic 14:43.460 --> 14:46.450 hypertrophy and I've made some suggestions for 14:46.450 --> 14:48.200 pre transplantation too. 14:48.200 --> 14:49.740 You are in these patients. 14:51.110 --> 14:52.360 Technical problems. 14:52.360 --> 14:55.150 Urologic with john 14:55.150 --> 14:55.850 Szaniawski, 14:55.850 --> 14:56.450 Major U. 14:56.450 --> 14:56.640 S. 14:56.640 --> 14:59.630 Air Force Medical Corps Staff Urologist 14:59.640 --> 15:00.550 Wilford Hall U. 15:00.550 --> 15:00.720 S. 15:00.720 --> 15:02.060 Air Force Medical Center, 15:02.300 --> 15:03.730 Lackland Air Force Base 15:05.070 --> 15:08.000 was produced through the mobile facilities of the Television 15:08.000 --> 15:08.580 division, 15:08.850 --> 15:10.290 Academy of Health Sciences, 15:10.290 --> 15:12.750 United States Army Fort SAm Houston 15:12.750 --> 15:13.430 texas.