M. Chebil

False penile fracture: report of 16 cases

We determined the value of diagnostic and therapeutic approaches of false penile fractures and the outcome of treatment. We retrospectively reviewed 16 cases of presumed penile fracture with a negative surgical exploration. Clinical presentation, technique of treatment and outcome were noted. The mean age was 39 years (17–64). Nine patients were injured during sexual intercourse. All the patients presented with the presumptive diagnosis of penile fracture. False penile fracture was evoked in one patient presenting a new erection. Surgical penile exploration was carried out for all the patients without any radiological explorations. It revealed nonspecific dartos bleeding in 10 cases and avulsed superficial dorsal vein in six cases requiring venous ends ligation. All the patients regained penile appearance and potency. We can hardly distinguish false penile fracture from ‘true’ penile fracture with certainty either clinically or radiologically, thus, surgical exploration is mostly necessary. The prognosis is excellent.

Segmental infarction of the testis: an exceptional complication of diabetes microangiopathy

We report a case of segmental infarction of the testis in a 55-year-old man. Past medical history included 12 years of type II diabetes and hypertension. The patient presented with a 2-month history of testicular pain and was found clinically and sonographically to have a testicular tumour. The pathological examination of the partial orchiectomy specimen revealed segmental infarction of the testicle secondary to diabetes microangiopathy. We propose diabetes microangiopathy as a localization and aetiology of segmental testicular infarction. A possible testicular sparing procedure through an inguinal approach may be considered in cases of testicular masses for which the clinical and imaging findings are suggestive of focal testicular infarction.

Post–Kidney Transplantation Lymphocele due to a Lymphatic Filariasis

Lymphocele is a well-known complication of renal transplantation. Presenting symptoms are nonspecific; most patients are entirely asymptomatic. Herein, we have reported a case of lymphocele due to an asymptomatic lymphatic Wuchereria bancrofti filariasis with deterioration of graft function. A 53-year-old man with end-stage renal disease secondary to vascular disease was admitted 40 days after transplantation with vague, isolated abdominal pain. An abdomen and pelvis ultrasound examination demonstrated a cystic structure in the renal hilus. Graft function deteriorated, so the patient underwent puncture of the lymphocele followed by povidone iodine sclerotherapy. In the percutaneous drainage, we noted a fine whitish strand 4-mm thick similar to the shape of the stent, a part of which seemed to go into the transplantation fossa. Parasitological examination showed an adult female worm of W bancrofti measuring 6 cm. The test for microfilaremia was negative. The patient was treated for 10 days with a combination of Ivermectin and Albendazole associated with Doxycycline. The collection rapidly decreased after worm treatment. This case describes a post-renal transplantation lymphocele due to asymptomatic lymphatic filariasis.

Kidney Transplantation During Autoimmune Diseases

Herein, we report the results of kidney transplantation in 9 of 376 patients who underwent kidney transplantation at our center between 1986 and 2007 because of chronic renal failure associated with autoimmune disease. Four of the 9 patients had systemic lupus erythematosus, 3 had Wegener granulomatosis, and 2 had Goodpasture syndrome. Six patients received organs from living donors, and 3 received cadaver organs. Infections were frequent and included cytomegalovirus and urinary tract infection in most cases. There was no difference in occurrence of metabolic and cardiovascular complications in our study patients compared with other transplant recipients. Incidence of allograft loss (n = 1) was similar to that in our entire transplantation population, with an overall rate of 2.9%. We conclude that kidney transplantation is a reasonable therapeutic option in patients with autoimmune disease with end-stage renal disease because of good graft and patient survival compared with kidney recipients without autoimmune diseases.

Le diverticule de l'urètre féminin, à propos de 21 observations

Purpose : Our goal is to study the clinical, radiological and therapeutic particularity of the female urethral diverticula via a retrospective study of 21 cases. Patient and methods : Twenty one females, with a mean age of 37 years (range 15 to 62 years) presenting an urethral diverticula, were treated between 1988 and 2000. Clinical examination made diagnosis in all cases. Cysto-urethrography chown a direct image of diverticula in 100% of cases and intravenous Pyelography in only 24% of cases. The urethral diverticula was excised via a trans-vaginal approach in all cases. Results : Eighteen patients had favourable immediate outcome. Three patients presented an urethrovaginal fistula treated surgically in one case and by bladder drainage in one case. The last patient refused treatment and she was lost to follow-up. After a median follow-up of 54 months (range 18 to 120) only three patients have some urinary urgency that was treated by anti-cholinergics. Conclusion : Female urethral diverticula is a rare disease, the diagnosis is easy and only surgical excision gives good results.

La fibrose rétropéritonéale

Resume Objectif Nous avons etudie les caracteristiques cliniques, therapeutiques et evolutives de la fibrose retroperitoneale. Methodes Nous avons analyse les observations de fibrose retroperitoneale diagnostiquees entre 1980 et 2002 dans notre hopital, a partir des resumes de 15 patients ayant une fibrose retroperitoneale (FRP). La surveillance therapeutique a ete fondee sur la biologie et la radiologie. Resultats Il s’agissait de 11 hommes et de 4 femmes dont l’âge moyen etait de 44,5 ans avec des extremes de 28 a 64 ans. Tous les malades avaient des douleurs essentiellement lombaires et abdominales. Un syndrome inflammatoire existait dans tous les cas et une insuffisance renale dans 11 cas. Les explorations radiologiques ont montre une hydronephrose uni ou bilaterale dans 14 cas et la plaque de fibrose dans 13 cas. Le traitement a ete constitue de corticoides seuls dans 9 cas, de chirurgie seule dans 3 cas et de chirurgie associee a la corticotherapie dans 3 cas. Dix rechutes a raison de 1 a 5 ont ete observees chez 4 malades apres arret des corticoides. Apres un delai moyen de suivi de 36 mois (18 j a 11 ans) 1 deces a ete observe, 12 patients avaient une fonction renale normale et 2 malades ont garde une insuffisance renale moderee. Conclusion Nous avons confirme la rarete de la fibrose retroperitoneale, la difficulte de son diagnostic, la frequence de la douleur, du syndrome inflammatoire et de l’insuffisance renale. Les corticoides sont efficaces et un suivi regulier est necessaire.

Malformative Uropathies and Kidney Transplantation

INTRODUCTION Malformative uropathies are a frequent cause of end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). Medical management of urinary tract infections and advances in surgical reconstruction procedures resulted in good outcomes of kidney transplantation among these patients. The aim of this article was to describe the epidemiological profiles and outcomes of patients who underwent transplantation for ESRD related to malformative uropathies. PATIENTS AND METHODS Among 493 kidney recipients at our center from 1986 to 2009, 47 had malformative uropathies as the cause of ESRD. We retrospectively studied the incidence of acute rejection episodes, acute tubular necrosis, as well as patient and graft survivals, comparing these results to those observed in patients without malformative uropathies using chi-square tests for qualitative parameters and nonpaired Student t tests for continuous variables. Log-rank tests were used for comparisons of survival curves. RESULTS The 47 patients, representing 9.53% of our kidney transplant recipients, included 27 men and 20 women (sex ratio=1.35) with an overall mean age of 27.6±9.1 years (range, 10-49). The common etiology was vesico-ureteral reflux (78.7%). Hemodialysis was the main RRT modality (68%) with a median duration of 41 months. Also, 82.9% of patients received transplants from living donors. Acute tubular necrosis occurred in 4 of these (8.5%) versus 22.06% of the other patients (P=.03). Acute rejection episodes were observed in 13 of these patients (27.6%) versus 23.1% of the other patients (P=not significant [NS]). After a cumulative follow-up period of 3744 months (median, 41.8 months), 5 patients had died (1.6 death/y/100 patients) and 5 had lost their allografts and returned to dialysis (1.6 case/y/100 patients). Graft survival rates at 1, 5, and 10 years were 97.8%, 93.2%, and 79.9%, which were comparable with 95.9%, 87.6%, and 78.9% among the other patients, respectively (P=NS). Patient survival rates at 1, 5, and 10 years were 100%, 88.5%, and 82.6% versus 96%, 87.6%, and 79.6%, respectively (P=NS). CONCLUSION Kidney transplantation in patients with malformative uropathies is increasingly frequent. The incidence of acute rejection episodes as well as patient and graft survivals were comparable with those of subjects without malformative uropathies.

Short- and long-term post–renal transplant follow-up at Charles Nicolle Hospital

years, 56.5%; 31 to #45 years, 33.5%; and .45 years, 4%. Primary renal disease was chronic glomerulonephritis in 85 cases (42.5%), chronic pyelonephritis in 43 (21.5%), nephroangiosclerosis in 17 (8.5%), hereditary nephropathy in 11 (5.5%), and unknown in 44 (22%). Initial renal replacement therapy (RRT) was hemodialysis (HD) in 155 cases (77.5%), continuous ambulatory peritoneal dialysis (CAPD) in 24 (12%) and the two techniques combined in 21 (10.5%). For LRD, only first-degree relatives who gave their informed consent were accepted. All patients received ABO compatible and cross-match negative kidneys. At least 3 units of blood transfusions were given to 161 patients (80.5%) and cytotoxic antibodies were screened. All patients received a combination of prednisolone: 2 mg/kg/d on day 0, tapered to 0.2 mg/kg/d on day 90 and azathioprine at 125 mg/d. Antilymphocyte globulin (ALG) or antithymocyte globulin (ATG) was used as prophylactic treatment of graft rejection in 98 cases (48%) during the first 15 days. Cyclosporine was administered in 112 patients (56%) twice daily orally at 5 mg/d beginning on day 3 to 15 days in LRD transplants with one identical haplotype and after corticoresistant acute rejection episodes. The dosages were adjusted to clinical state and cyclosporine blood level (radioimmunoassay). Acute rejection episodes were treated with a combination of pulses of methylprednisolone and ALG/ATG in 75 cases. OKT3 was introduced in six cases when ALG/ATG failed to reverse the rejection. Mycophenolate mofetil was used in 11 cases with cyclosporine nephrotoxicity. The results were expressed as mean 6 standard deviation (SD). Comparisons were made with chi squared test for categorical variables and PLSD Fisher’ test for continuous variables. The survival rates were computed using the actuarial method. P , .05 was considered statistically significant. RESULTS The waiting time on dialysis was 28 6 22 months (1 to 119 months). For LRD, the donors were 96 (52.7%) siblings, 84 (46.2%) parents, and 2 children. HLA matching was 0 mismatches (MM) in 48 cases (26.4%) and 3 MM in 134 (73.6%). Their mean age was 38.6 6 13.4 (16 to 65) years. For CAD, HLA matching was 1 to 6 MM. The cytotoxic antibodies were positive in 27% of cases. Acute tubular necrosis (ATN) occurred in 26 cases (14.3%) of LRD and in 3 (16.7%) CAD. All those patients were hemodialyzed requiring 1 to 10 sessions, but all recovered. The difference between the two groups was not statistically significant (P 5 .07). The mean time of warm ischemia was 44 6 13 minutes for patients who have expressed ATN and 41.9 6 10.9 for those without ATN. The mean time of cold ischemia for CAD was 26.8 6 6 hours. Acute rejection was encountered in 16 (33.3%) cases of LRD with 0 MM, 80 (59.7%) cases of LRD with 3 MM, and 14 (77.8%) cases in the CAD group. The differences between the three groups were statistically significant (P , .0009). Complications Infectious complications were very common (86% of cases). Viral infections occurred in 40% of cases, mostly CMV (21%) and herpes (14%). No HIV infection was seen. Bacterial infections occurred in 60% of cases, mostly urinary tract infections (49%), septicemia (11.5%), and bronchopulmonary infections (5%). Six patients had scabies. Urologic complications occurred in 31 cases: 14 (7%) urinary leaks, 6 (3%) urinary stenosis, 2 ureteral compressions, 4 lymphoceles, 3 urinary lithiasis, and 2 urinary tuberculosis. Vascular complications were seen in eight cases: two arterial thrombosis, two venous thrombosis, three arteriovenous fistulae, and one perirenal hematoma. We noted recurrence of focal segmental glomerulosclerosis in six cases and glomerulonephritis de novo in two cases.

Short- and Long-Term Outcomes of Living Donors in Tunisia: A Retrospective Study

Despite initiatives to increase cadaveric donation, there is still a shortfall in donor organs. Kidneys from living donors now makes a significant contribution to increasing the number of organs available for transplantation in Tunisia. We performed a retrospective study of 405 kidney transplantations, including 321 (79.3%) from living donors performed from June 1986 to December 2007. We obtained information on only 162 (50.4%), namely, 64 men (39.5%) and 98 women (60.5%), whose mean age at the time of donation was 42.3 ± 12.2 years. Twelve (8.22%) perioperative complications occurred: wound infections (n = 4), pneumothorax (n = 4), phlebitis (n = 1), hematomas (n = 2), and urinary infection (n = 1). The mean follow-up period was 117.4 ± 74.4 months. Hypertension occurred in 42 donors (25.9%) with mean values of 134 ± 20 for systolic and 79 ± 10 for diastolic blood pressure. Twelve donors (7.4%) developed proteinuria (mean proteinuria, 0.08 ± 1.25 g/d). Renal insufficiency was found in 28 donors (19.44%), 2 of whom developed chronic renal failure requiring dialysis at intervals of 36 and 84 months. In both cases, we diagnosed a familial form of focal segmental glomerulosclerosis. Two donors (1.2%) died within 10 years after kidney donation due to senility. The relatively favorable outcomes suggest that living-donor kidney transplantation is an acceptable approach, in view of the superior results it yields in recipients. However, efforts to increase the number of cadaveric donors in Tunisia should be made. It is also important to develop a registry of long-term kidney function after kidney donation.

Removal of kidneys from living donors: Technical or ethical problem?

Abstract IN JUNE 1986, a renal transplanation program was initiated in Tunisia. Because of social factors, the arena of renal transplantation has shown great progress with grafts provided mainly from living related donors. One hundred forty-four cases of nephrectomy were performed on living related donors (NLRD) at Charles Nicolles Hospital in Tunis. This study determines whether the risks that donors run after grafting are insignificant or, relevant, and whether we should continue or give up this technique.