Mahendra Bhandari

Substitution urethroplasty for anterior urethral strictures: a critical appraisal of various techniques

To retrospectively compare the outcome of various techniques of substitution urethroplasty.

Effect of lovastatin, an HMG CoA reductase inhibitor, on acute renal allograft rejection

3‐Hydroxy‐3‐methyl glutaryl coenzyme A (HMG CoA) reductase inhibitors are established anti‐lipidemic agents. They also exert immunomodulatory effects. Two recent reports suggest that pravastatin may be useful in decreasing the incidence and severity of acute rejections (ARs) in heart and kidney transplant recipients. We undertook this prospective, randomized, placebo‐controlled, double blind trial to investigate the effect of lovastatin on acute renal allograft rejection. Sixty‐five consecutive, one‐haplotype‐matched, living related first renal transplant recipients were randomized to receive either lovastatin 20 mg/d or placebo for 3 months, in addition to cyclosporine, azathioprine, and steroids. Lipid levels, AR episodes, and liver and muscle enzymes were followed for 3 months post‐transplant. At the end of the study period, lovastatin had successfully controlled lipid levels. However, there was no effect on AR episodes (15.15% in the treatment group vs. 18.75% in the placebo group).

EXPANDING THE LIVING RELATED DONOR POOL IN RENAL TRANSPLANTATION: USE OF MARGINAL DONORS

Purpose: In a living related transplantation program it is not always possible to find an ideal donor. Sometimes the only available donor in the family has some benign disease or suboptimal renal anatomy or physiology, or is too old to be accepted and defined as a marginal donor. However, with proper screening the donor pool can be increased by accepting these marginal donors and treating the benign diseases which is beneficial to the donor. We evaluate the outcome of grafts from marginal donors. Materials and Methods: From July 1988 to August 1997, 581 live related transplantations were performed. Of the donors 52 were older than 60 years and 34 had associated benign renal or nonrenal anomaly or disease. These donors were accepted after thorough questioning and consultation with family members. The recipients of graft from elderly donors were evaluated for the number of rejections, serum creatinine at last followup and graft survival. Results: Of the recipients 52 received grafts from elderly donors with a mean age of 62.6 ± 3.7 years. Mean followup was 34.14 ± 0.7 months. The 2 and 5-year actuarial graft survival was 96% and 74%, respectively. Creatinine was normal (less than 1.5) in 37% of recipients and 1.5 to 2.5 mg.% in 46%. The rejection rate in postoperative month 1 was 29%. All donors underwent simultaneous surgery to treat the benign disease, and all did well after surgery. Conclusions: By accepting these marginal donors a 14.6% increase in the living related donor pool was achieved without compromising recipient or donor safety. Otherwise these recipients would have been forced to undergo unrelated transplantation or be maintained on dialysis, which is particularly difficult in a developing country. Donors with associated disease benefited from cure.

Is povidone iodine an alternative to silver nitrate for renal pelvic instillation sclerotherapy in chyluria

To compare the efficacy and toxicity of 1% silver nitrate, 0.2% povidone iodine and 50% dextrose in renal pelvic instillation sclerotherapy (RPIS) for chyluria.

Should Upper Ureteral Calculi be Manipulated before Extracorporeal Shock Wave Lithotripsy? A Prospective Controlled Trial

Whether all upper ureteral stones must be manipulated before extracorporeal shock wave lithotripsy (ESWL*) is an ongoing controversy. In a prospective trial, symptomatic patients with solitary upper ureteral calculi less than 1 year in duration were alternated between ESWL in situ and pre-ESWL stone manipulation. Pretreatment excretory urograms were assessed for stone size and degree of proximal hydroureteronephrosis, which was graded from zero (no dilatation) to 3 (severe dilatation). Stone manipulation was done with the patient under intravenous sedation and local anesthesia. A total of 4,000 shock waves was given in a single session using Siemens Lithostar Plus, and treatment was repeated on days 4, 15 and 30 if required. The patients were evaluated 3 months after onset of therapy with excretory urogram and urine culture. Seventy patients qualified for the study (group 1-35 in situ and group 2-35 stone manipulation) and were comparable in relation to age and sex, stone size and degree of hydronephrosis. There was no significant difference between the 2 groups regarding the number of sessions (group 1-1.86 +/- 1.2 and group 2-2.03 +/- 1.2) or shock wave requirement (group 1-5,705.8 +/- 3,536.9 and group 2-5,549.1 +/- 3,837.2) for stone fragmentation. The degree of proximal dilatation did not contribute significantly towards the outcome (F ratio 0.675, p = 0.57). A total of 30 patients (85.5%) in group 1 had a satisfactory outcome at 3 months, while 3 (8.5%) had significant residual calculi and 2 stones could not be fragmented. Of the manipulated stones 33 (94%) were successfully cleared, while 2 patients required auxiliary procedures. Ureteroscopy was required in 1 patient for upward migration of the stent. Morbidity in both groups was comparable. We conclude that upper ureteral stones should be treated in situ to avoid the morbidity of manipulation.

Management of Staghorn Calculus: Analysis of Combination Therapy and Open Surgery

Objective: To assess the role of primary open surgery versus the recommended combination approach (percutaneous and lithotripsy) to treat staghorn calculi in a developing country. Patients and Methods: Available records (n = 91) of patients with staghorn managed during the last 4 years were retrieved. Patients were placed in two groups, open surgery and combination group, according to the primary procedure chosen by the patient. Demographic data in two groups was comparable in most of the respects except that renal failure patients were more in the combination group. Stone clearance, major residue, auxiliary procedures, morbidity, hospital stay and the cost were studied in the two groups for comparison. Results: Complete clearance could be obtained in 66 and 59% with open and combination method respectively. Major residue (>16 mm2) was present in 21% of open and 38% of the combination group. In patients with primary stone burden <900 mm2, the total clearance rates were 66 and 60% in open and combination group, respectively. Total clearance was not affected by caliceal dilatation, total stone burden, pelvic and caliceal bulk separately or their ratio, as arrived by logistic regression analysis. The incidence of haematuria in the combination group was marginally higher, probably due to more renal failure patients in this group. Hospital stay in the two groups was comparable (13.0 days in combination vs. 12.1 days for open). The cost of treatment with combination group was significantly higher. Conclusion: Open surgery for staghorn is still an economically viable option for difficult stone disease, specially in a developing country, with comparable efficacy, favourable morbidity and hospital stay.

Functional Bladder Neck Obstruction: A Rare Cause of Renal Failure

We studied 7 men and 6 women (average age 33 years) who presented in renal failure with obstructive voiding symptoms or retention. Of these patients 11 had a dilated upper tract and 2 had shrunken kidneys. Mean serum creatinine at presentation was 7.0 mg./dl. No abnormality was noted on cysto-panendoscopy, retrograde urethrography and voiding cystourethrography. The patients were initially treated with clean intermittent self-catheterization following 7 to 10 days of indwelling catheterization. The majority of patients had low pressure and low flow rate at initial presentation but high end filling pressure (mean 35.3 cm. water), high voiding pressure (mean 118.9 cm. water), high opening pressure (mean 95.3 cm. water) and low peak flow (mean 5.7 ml. per second) on video pressure flow electromyography. The external sphincter was relaxed during voiding but the bladder neck opened intermittently or inadequately. No proper funneling of the bladder neck was seen. Thus, functional bladder neck obstruction was considered to be responsible for obstructive voiding in these patients. Of the patients 3 void to completion with the help of alpha blockers alone, 5 underwent bladder neck incision and are voiding well, and 5 were practicing clean intermittent self-catheterization at last followup. Serum creatinine returned to near normal in 10 patients. End stage renal failure persisted in 2 patients, 1 of whom underwent renal transplantation and is voiding well but the other died without having undergone renal replacement therapy. In the remaining patient serum creatinine was stable at 3.2 mg./dl. Mean serum creatinine at 6 months of followup was 2.33 mg.%. Bladder neck obstruction is a rare cause of renal failure which can be corrected if treated appropriately.

Long-term allograft survival in renal transplantation from elderly donors

DONOR age affects graft survival and allograft function. Controversy exists concerning graft survival and utilisation of renal allografts from elderly donors. There are few reports that suggest that there is no significant difference in graft survival from younger and older donors while others suggest that allografts from elderly donors have poorer outcome. The majority of transplants in India are being performed from living related donors. But the shortage of organs justifies the attempts to use all possible sources for renal transplantation (RT). We analyzed our renal transplant data to see if kidneys from elderly (.60 years) donors were more likely to be rejected and what was the survival of renal allografts from elderly donors.

Urethral Reconstruction in Patients Suffering from Aphallia: A Reconstructive Challenge

Objective: To document our experience (at a tertiary health care center) of reconstruction of the urethra in 3 male patients suffering from aphallia and congenital urethrorectal fistula as well as their long-term follow-up. Methods: Extensive single-stage urethroplasty in 3 patients suffering from aphallia was performed. Prior to that, neophallus reconstruction was done in all 3 patients after puberty. In a single stage, we used oral mucosa and pedicled penile skin onlay for anterior urethra reconstruction and groin-based pedicle (Singapore) flap for posterior urethra substitution surgery. The current follow-up is between 2 and 5 years. During the last follow-up, the patients also answered questions from a validated patient-reported outcome measure and quality of life questionnaire. Results: All the 3 patients are voiding well in the standing position with a mean Qmax of 14 ml/s. None of them has any problems related to the neourethra as per their last follow-up. All 3 patients were satisfied with the surgical procedures related to the aphallia correction and stated that the surgery did not interfere with the quality of their lives. Conclusion: Reconstruction of the urethra from pedicled skin flap combined with buccal mucosa graft urethroplasty gives durable and satisfactory long-term results.

Cyclosporine level: which single-point estimation of drug level is the best?

CYCLOSPORINE (CyA) has a narrow therapeutic window, with potential side effects and risk of rejection from underdosing. Area under the curve (AUC) of blood CyA concentration versus time is the best indicator of systemic drug exposure, but this is cumbersome and impractical for routine clinical use. Traditionally, trough blood levels (CO) have been used. Cyclosporine pharmacokinetics in Indian patients may not be identical to Western patients. Adequate study in this patient population is required to know which single-point drug level estimation is the best.