Denis M. Murphy

Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion

Objectiveu2002To compare the surgical outcome in patients with or with no bowel preparation before cystectomy and ileal conduit urinary diversion, specifically assessing local and systemic complications.

Transplant Nephrectomy Over 20 Years: Factors Involved in Associated Morbidity and Mortality

Of 1,048 renal transplants performed between 1971 and 1990, transplant nephrectomy was performed in 86 (8.2%). Mean patient age was 33 years (range 3.8 to 66.5). Postoperative complications occurred in 60% of the patients, including wound infection in 20% and major hemorrhage in 4 patients. The external iliac artery was ligated in 4 patients. The incidence and severity of the complications were greater in patients with acute rejection. Four patients died: 1 of ischemic bowel and metastatic carcinoma, 1 of pulmonary embolism, and 2 of sepsis and disseminated intravascular coagulation. The nephrectomy rate increased significantly (p < 0.005) when cyclosporine A was initially introduced. Added care is necessary when new immunosuppressants are used. The majority of our failed transplants were left in situ without compromising overall patient well-being.

Renal transplantation in patients with an augmentation cystoplasty

Objective To retrospectively review our experience over a 10‐year period of renal transplantation in patients with augmented bladders and thus assess the safety of this procedure.

THE ROLE OF INTRAOPERATIVE HEPARIN IN CYCLOSPORINE TREATED CADAVERIC RENAL TRANSPLANT RECIPIENTS

PURPOSEnWe analyze the effect of intraoperative heparin in cadaveric renal transplantation.nnnMATERIALS AND METHODSnWe examined the records of 100 consecutive cadaveric transplant recipients who received 5,000 units of heparin at the time of vascular clamping (group 1), and compared the incidence of graft thrombosis and postoperative hemorrhagic complications to 100 consecutive cadaveric transplant recipients who did not receive heparin (group 2). The groups were similar in terms of donor age, sex, number of transplant recipients, sensitization, multiple vessels, delayed graft function and human leukocyte antigen mismatch. All patients received cyclosporine based triple therapy immunosuppression. All explanted grafts were examined histologically to rule out hyperacute rejection.nnnRESULTSnThere was no statistical difference between the 2 groups. The overall incidence of graft thrombosis was 5% (6% in group 1 and 4% in group 2). There was a greater need for blood transfusion in group 1, with 25 patients requiring transfusion postoperatively versus 14 in group 2.nnnCONCLUSIONSnIntraoperative heparin did not reduce the incidence of graft thrombosis in this retrospective study. It did increase the postoperative blood transfusion requirements. As a result of this analysis, we have abandoned its use.

Septicemia after transurethral prostatectomy

Septicemia occurred in 18 of 1,604 patients subjected to transurethral resection (TUR) of the prostate. Six patients died postoperatively, 4 of septicemia. In 11 patients septicemia was provoked by TUR in the presence of urinary infection and in the absence of appropriate antibiotic cover. Septicemia was provoked by catheter removal in 2 similarly infected patients. In the remaining 5 patients the urine was sterile at operation but became infected prior to catheter removal, and this maneuver precipitated septicemia.

LONG-TERM FOLLOWUP OF CADAVERIC RENAL TRANSPLANTATION IN PATIENTS WITH SPINA BIFIDA

PURPOSEnAccess related problems in hemodialysis and peritoneal dialysis are increased in cases of spina bifida due to vascular and body habitus limitations. Reports of renal transplantation in this patient group are exceedingly rare. We report long-term followup data on cadaveric renal transplantation for end stage renal failure in cases of spina bifida.nnnMATERIALS AND METHODSnBetween February 1986 and April 2000, 17 cadaveric renal transplants were performed in 11 females and 5 males with spina bifida. Mean age at transplantation was 20.2 years (range 10 to 35). Of the patients 11 were wheelchair bound and 5 were independently mobile. Before transplantation surgical management of the urological tract included clean intermittent self-catheterization in 3 cases, enterocystoplasty and clean intermittent self-catheterization in 8, and ileal conduit urinary diversion in 5. A total of 14 patients were on renal replacement therapy before receiving the graft. Cyclosporine based triple therapy was administered to maintain immunosuppression in all cases and antithymocytic globulin was given for induction in 7.nnnRESULTSnSix grafts have failed, including 1 in a patient who underwent successful re-transplantation. Median graft survival was 7.23 years. Two patients died after graft nephrectomy. At a mean followup of 52.8 months (range 1 month to 14 years) 11 of 17 grafts are functioning with a mean serum creatinine of 112.7 +/- 29.4 mmol./l.nnnCONCLUSIONSnThese data demonstrate the feasibility of cadaveric renal transplantation in patients with spina bifida and end stage renal failure. We currently recommend that these patients should not be deprived of the benefits of renal transplantation.

Transplantation of Kidneys from Pediatric Cadaver Donors to Adult Recipients

Pediatric donors (less than 12 years old) are a potentially important source of kidneys for adult recipients. Previous reports of decreased graft survival and increased complication rates have made surgeons wary of using such kidneys. In 64 kidneys from younger donors transplanted to adult recipients the delayed graft function rate (41 versus 42%), and 2 and 3-year graft survival rates (67 versus 72% and 61 versus 65%, respectively) were similar to those seen with kidneys from adult donors. Kidneys from donors 24 months old or less experienced an 80% rate of graft loss at 1 year. When these kidneys are excluded the 1-year graft survival rate was similar to kidneys from older and younger donors (70 versus 77%). Mean serum creatinine at 1 year was similar in both groups (155 +/- 21 versus 151 +/- 10). Pediatric kidneys except those obtained from donors 2 years old or less are suitable for adult recipients. However, kidneys from very young donors may be more appropriate to pediatric recipients.

Antimicrobial Agents for the Prevention of Urinary Tract Infection in Transurethral Surgery

Chemoprophylaxis and disinfection of the operation site for the prevention of bacteriuria after a transurethral operation were assessed in controlled, prospective studies in men with sterile urine preoperatively. The majority of the control patients (65 per cent) suffered postoperative bacteriuria compared to 38.6 per cent after perioperative disinfection with chlorhexidine and 10 per cent or less after each of 2 other regimens (intramuscular cephradine followed by oral nitrofurantoin and chlorhexidine disinfection followed by oral nitrofurantoin). The latter regimen is preferred since it avoids the use of agents with systemic action.

Ureterovaginal Fistula: A Report of 12 Cases and Review of the Literature

Ureterovaginal fistula is an uncommon complication of pelvic operations, seen most often after Wertheims hysterectomy. We report 12 cases of ureterovaginal fistulas seen during a 20-year period, all of which followed operations for benign gynecologic conditions. Most patients had no urinary symptoms until the sudden onset of incontinence 1 to 4 weeks postoperatively. Diagnosis was established readily by a combination of excretory urography, cystography, cystoscopy, retrograde pyeloureterography and dye studies. In our series only 1 patient was treated by primary nephrectomy, while 11 underwent ureteroneocystostomy: 2 with a Boari flap and 9 by a direct method. Reconstruction failed in 2 patients, 1 of whom required a secondary nephrectomy.

Post-operative urinary infection and septicaemia in urology

Abstract Transurethral instrumentation in men with normal urine was often followed by urinary infection. This rarely caused harm unless the patients had another operation. Prophylactic ampicillin reduced the incidence of urinary infection but is not recommended for routine use. Over 2 per cent of transurethral prostatectomies in patients with already infected urine, not covered by appropriate antibiotics, resulted in septicaemia. Septicaemia sometimes began at operation, sometimes later when the catheter was removed. It should be prevented by appropriate chemotherapy based on rapid urine culture and sensitivity tests shortly before operation.