Renal transplantation in patients with urinary diversion: a case-control study.
BACKGROUND: Renal transplantation in Sweden in patients with ileal conduits or continent reservoirs was investigated in order to compare the outcome with regard to graft and patient survival as compared to controls. METHODS: Patient data from the four transplantation centres in Sweden were collected on: treatment prior to transplantation, time needed for the operative procedure, and postoperative care and outcome in terms of renal function as well as graft and patient survival at 1 and 5 years. The pattern of urinary tract infection was also investigated. Each case with urinary diversion was matched with two non-diabetic controls. RESULTS: Ten male and 12 female cases were found who had received 27 grafts between 1982 and 1996. Five patients had a Kock reservoir and 17 had a Bricker conduit. The time needed for the transplant procedure was significantly longer in the case group. After matching the case group with 54 controls, we found that the renal function was similar in both groups. Graft and patient survival was similar in both groups, over 90% after 1 year. Graft survival was about 70% after 5 years. Postoperative surgical complications in the case group were only seen in a few cases. The pattern of bacteria causing urinary tract infection was slightly different among the patients with ileal conduits or continent reservoirs. CONCLUSION: Patients with ileal conduits or continent reservoirs have similar graft and patient survival rates as the general kidney transplant population. The presence of constant bacteriuria did not adversely affect survival. Prophylactic antibiotic treatment seems not to be warranted. There appears to be no indication for native nephrectomy, except in selected cases. The study did not show any advantage with regard to continent reservoirs vs ileal conduits. (+info)
Circulatory reflexes in tetraplegics during artifical ventilation and general anaesthesia.
The arterial blood pressure, heart rate and electrocardiograph were recorded, and plasma electrolytes, arterial blood gases and pH, and plasma catecholamines were estimated in seven patients with physiologically complete cervical spinal cord transections who needed intermittent possitive pressure ventilation (I.P.P.V.) or were undergoing urological surgery under general anaesthesia. In the tetraplegics on I.P.P.V., bradycardia, and in two patients even cardiac arrest, occurred during tracheal suction, especially in the presence of hypoxia. In one tetraplegic being anaesthetised, cardiac arrest occurred during endotracheal intubation. This reflex bradycardia and cardiac arrest appeared to be due to a vago-vagal reflex, unopposed by sympathetic activity or by the pulmonary (inflation) vagal reflex. Atropine was effective in preventing this reflex. In the tetraplegics undergoing urological surgery, severe hypertension resulting from visceral stimulation was effectively reduced by halothane. In these patients, control of arterial blood pressure with lower concentrations of halothane may also be achieved with I.P.P.V. (+info)
The use of halothane anaesthesia to control autonomic hyperreflexia during trans-urethral surgery in spinal cord injury patients.
Forty-five spinal cord injury patients undergoing trans-urethral surgery were anaesthetised using a mixture of nitrous oxide and halothane in oxygen. The use of halothane to control the hypertensive manifestations of surgically induced autonomic hyperreflexia is discussed. (+info)
Urodynamic study of enhanced continent mechanism using tapered ileum as continent urinary reservoir.
OBJECTIVE: To investigate the effect of extramural support from the pouch and abdominal wall to enhance the continent mechanism of tapered ileum. METHODS: A total of 24 patients underwent a procedure in which an ileal segment was tapered into an efferent tube, of which a part was placed between the back surface of the rectus muscle and the ileal pouch wall. The internal orifice of the tapered ileum was anastomosed to the ileal pouch and its external orifice was anastomosed to the umbilicus. A urodynamic study of the efferent tubes and pouch was done 1.5 to 3 months and 6 to 24 months postoperatively. RESULTS: One patient died of heart disease 55 days postoperatively, while 22 of the remaining 23 were completely continent day and night. At 1.5 to 3 months, the urodynamic study of the efferent tubes demonstrated that the maximum closure pressure with a full pouch was 46 - 124 cmH(2)O (91.26 +/- 15.71 cmH(2)O) and with an empty pouch was 34 - 84 cmH(2)O (67 +/- 10.60 cmH(2)O). The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -11.78 and P = 0.00001). At 6 to 24 months, a second urodynamic study was performed on 18 cases, demonstrating a reservoir capacity of 420 to 750 ml (481.67 +/- 78.83 ml). Reservoir pressure was 6 to 9 cmH(2)O (7.17 +/- 1.17 cmH(2)O) when the pouch was filled to 50 ml, and 16 to 35 cmH(2)O (24.12 +/- 5.61 cmH(2)O) when it was filled to maximum capacity. There was no contractive wave during the filling in any patient. Maximum closure pressure in the efferent tube was 80 to 194 cm H(2)O (98.89 +/- 26.34 cmH(2)O) when the pouch was filled with saline, and 64 to 128 cmH(2)O (74.78 +/- 14.54 cmH(2)O) when the pouch was empty. The difference in mean maximum closure pressure in the full and empty pouches was statistically significant (t = -7.58 and P = 0.00003). CONCLUSIONS: This study indicates that the continent mechanism of tapered ileum may be greatly enhanced by extramural support from the abdominal and pouch walls. (+info)
Simultaneous surgical treatment of abdominal aortic aneurysm and carcinoma of the bladder.
OBJECTIVE: The purpose of this study was to evaluate the short-term and long-term results of simultaneous surgical treatment of coexisting abdominal aortic aneurysm and bladder carcinoma. METHODS: A prospective study was carried out to compare patients undergoing simultaneous surgical treatment of abdominal aneurysm and bladder carcinoma with control patients undergoing surgery for either one of the two diseases alone. From January 1995 to December 2000, 16 consecutive patients were seen with concomitant abdominal aortic aneurysm and bladder carcinoma at our institutional referral center. All patients underwent a standard operative protocol that included aneurysm graft replacement, radical cystoprostatectomy, and urinary reconstruction. Endovascular treatment of the aneurysm was considered in the last 2 years of the study. After each simultaneous treatment case, two control patients were selected according to the same type of vascular or urinary procedure, respectively, and pathologic staging. The analyzed endpoint was mortality, and confounder variables included common and disease-specific risk factors. Frequencies of vascular, urologic, and systemic complications were carefully considered with special attention to graft infection and tumor recurrence. RESULTS: Endovascular treatment was not performed for morphologic reasons. No perioperative mortality was observed. A trend toward inferior survival rates in simultaneously treated patients was observed in the early follow-up period, but survival analysis with log-rank test showed no statistical difference among the groups (P =.19). Cox proportional hazard model results proved no influence of the different group treatments on survival (P =.49) and no influence of age and risk factors, except for preoperative renal status (P =.015). The increased mortality rate of the simultaneous treatment group could be ascribed to the presence of preoperative moderate renal insufficiency in two study group patients. Long-term survival of treated patients is mainly dependent on cancer progression. Graft infection and other vascular complications were not observed. Systemic and urologic complications were similar in study and control groups. CONCLUSION: This study shows that the simultaneous surgical approach to coexisting abdominal aortic aneurysm and transitional cell carcinoma of the bladder represents a suitable choice of treatment in highly specialized centers, but patients with preoperative renal insufficiency should be carefully evaluated. Endovascular treatment represents an appealing alternative whenever indicated. (+info)
Hypertrophy changes the muscarinic receptor subtype mediating bladder contraction from M3 toward M2.
Major pelvic ganglion electrocautery (MPGE) and spinal cord injury in the rat induce bladder hypertrophy and a change in muscarinic receptor subtypes mediating bladder contraction from predominantly M3 to a combination of M2 and M3. To determine whether this is a result of bladder hypertrophy or denervation, we studied the following groups: sham-operated controls, urinary diversion (DIV), MPGE together with urinary diversion (DIV-DEN), bilateral MPGE (DEN), bladder outlet obstruction (BOO), and MPG decentralization (MPGDEC). The degree of bladder denervation was determined by the maximal carbachol response normalized to the response to electric field stimulation. Receptor subtype density was determined by immunoprecipitation. The affinity of subtype-selective muscarinic antagonists for inhibition of carbachol-induced contractions was used to determine the subtype-mediating contraction. DEN, MPG-DEC, and BOO bladders were hypertrophic whereas DIV bladders were atrophic compared with sham operated. Bladder contraction in sham-operated, DIV, and DIV-DEN was mediated by the M3 receptor subtype, whereas the M2 subtype participated in contraction in the DEN, MPG-DEC, and BOO groups. The hypertrophied bladders had an increase in total and M2 receptor density while all experimental groups showed a reduction in M3 receptor density. Thus bladder hypertrophy, independent from bladder denervation, causes a shift in the muscarinic receptor subtype mediating bladder contraction from M3 toward M2. (+info)
Meckel's diverticulum: an alternative conduit for the Mitrofanoff procedure.
The Mitrofanoff procedure is a versatile technique that is successfully used in achieving continent urinary diversion for a wide variety of urological conditions. Appendix and usable segment of ureter are commonly employed for this purpose and provide desirable results. This communication describes a teenage girl with lumbosacral agenesis and neurogenic bladder in whom Meckel's diverticulum was successfully used for the Mitrofanoff procedure. (+info)
USE OF ILEAC SEGMENT CONDUITS IN UROLOGICAL OPERATIONS.
The cases of 50 patients in whom ileac segments were utilized in urological operations were reviewed. The complications were more prevalent in patients with malignant disease. The results were particularly gratifying in children with neurogenic vesical dysfunction. Evisceration was the most common of the serious immediate complications. The results were as good in cases in which the ureters were not "splinted" as they were when splinting catheters were used. Four deaths were recorded during the hospital stay. Overall, the procedure was thought to be satisfactory in the management of otherwise serious, and often hopeless, urologic problems. (+info)