Purpose: To evaluate the efficacy of new super pulse thulium fiber laser (SP TFL) and compare it with holmium laser for ureterolithotripsy. Patients and Methods: A total of 174 patients with solita...

Clinical Comparison of Super Pulse Thulium Fiber Laser and High-Power Holmium Laser for Ureteral Stone Management

Intestinal ischemia is reported to be the most common gastrointestinal complication of renal transplantation and a potential cause of morbidity and mortality. The recent use of more potent immunosuppr

Cytomegalovirus and Clostridium difficile ischemic colitis in a renal transplant recipient: a lethal complication of anti-rejection therapy?

Intravesical explosion during transurethral resection of the prostate (TURP) is an extremely rare event. It might be associated with various degrees of bladder injury ranging from simple mucosal tear to rupture of the bladder. It is believed that intravesical explosion occurs due to formation of explosive gases in the bladder during TURP and its admixture with air. One case of intravesical explosion during TURP resulting in complete intra- and extraperitoneal bladder rupture at our institution is described. The management of this dreaded complication involves open surgery. Although rare, this complication is preventable by taking precautions.

Explosive gas formation during transurethral resection of the prostate (TURP).

Background
Renal transplantation is the treatment modality of choice for patients with end stage kidney failure. We present our experience of graft and patient survival of initial 500 renal transplants performed between May 1991 and July 2006, at Army Hospital (R&R).

Renal Transplantation - An Experience of 500 Patients

The ideal surgical laser for the treatment of soft tissue pathology should possess both ablative and hemostatic abilities. As well, for use in urologic conditions the laser must also be suitable for endoscopic use. The Holmium:YAG laser possesses these qualities and in preliminary clinical use has demonstrated a variety of potential urologic applications. In this study we review our initial experience with the Holmium:YAG laser over a 18 month period. A total of 51 patients underwent 53 procedures for a variety of soft tissue conditions including: bladder tumor ablation (25), incision of ureteral stricture (15), incision of urethral stricture (6), treatment of ureteropelvic junction obstruction (3), incision of bladder neck contracture (2), and ablation of a ureteral tumor (2). Satisfactory hemostasis was achieved in all cases. Procedures were considered successful (no further intervention being required to treat the condition) in 81% of the cases. Two patients with dense bladder neck contractures required electroincision under the same anesthetic for completion of the procedure. A single complication, that of urinary extravasation following incision of a urethral stricture resolved with conservative management. In summary, the Holmium:YAG laser has demonstrated safety and proficiency in the treatment of a variety of urologic soft tissue conditions.

Soft-tissue applications of the holmium:YAG laser in urology

Albert Einstein can be considered the ‘father’ of laser (light amplification by the stimulated emission of radiation) technology [1]. It was almost seven decades later in 1968 that Mulvaney and Beck [2] developed a ruby laser capable of calculus fragmentation with considerable expenditure of energy, resulting in excessive heat production. The thermal effects on the surrounding tissues precluded its clinical use. Attempts were subsequently made to use continuous wave carbon dioxide and Neodymium : YAG (Nd: YAG) lasers. The inability to transmit carbon dioxide laser via non-toxic fibres suitable for endoscopic applications and thermal effects to adjacent soft tissues associated with the Nd:YAG devices limited their clinical usefulness [3]. Based on the initial experience with these lasers, an understanding of the necessary requirement for successful laser lithotripsy became apparent, including the ability to deliver energy through optical fibres, need to limit distant thermal effects and production of a shock wave of sufficient force to exceed the tensile strength of the stone [4]. The first commercially successful laser lithotrite was the coumarin pulse dye laser but it could not fragment cystine stones. In clinical use the pulsed dye laser has been safe and effective in Nd: YAG and Alexandrite lasers [5, 6]. The holmium: YAG (Ho: YAG) laser is the newest wavelength device available for urological applications. Investigational work for lithotripsy with the Ho: YAG laser dates back to 1990 and clinical use began in 1993. This multi-purpose laser combines the qualities of carbon dioxide and Nd: YAG laser in providing both tissue cutting and coagulation in single device. Since the holmium wavelength can be transmitted down optical fibres, it is especially suited for intracorpreal/endoscopic lithotripsy.

Holmium : YAG Laser for Intra Corporeal Lithotripsy.

Intravesical explosion during transurethral resection of the prostate (TURP) is an extremely rare but dreaded complication and results in rupture of the bladder. It is believed that intravesical explo

Intravesical Explosion during Transurethral Resection of Prostate – A Reminder

Background: This study is a retrospective analysis of urological complications and their treatment in our series of live-donor renal transplantation. Material and Methods:&

Urological complications of live related donor renal transplantation: 13 years' experience at a single center.

With improved survival of its citizens and the changed pattern of their diseases, India tends to focus on certain pet problems such as ischaemic heart diseases and human immunodeficiency virus (HIV) infections ignoring the burden of chronic organ failures and end stage diseases. A philosophical attitude towards organ failure secondary to chronic diseases and certain indulgences such as alcoholism is prevalent. A national apathy associated with these diseases also exists, as the treatment options are resource consuming, limited and expensive. Understandably, the cure by eventual organ replacement remains only a dream for the vast majority of these patients.

The prevalence of chronic organ failure and end stage diseases in India, excepting chronic renal failure (CRF) and end stage renal disease (ESRD), is not known. The prevalence of CRF in our adult population varies from 0.785% [1] to 1.39% [2]. Sadly ESRD population in our country tends to be predominantly young due to delay in diagnosis and absence of sponsored measures to reduce renal deterioration in patients with CRF [3]. Due to a paucity of free renal replacement therapy (RRT) in Government hospitals and the high costs of dialysis, both haemo and peritoneal, it is estimated that only about 10% of these patients get some form of RRT [3]. In the medium and long term, renal transplantation (RTx) is the most economical form of RRT and the best mode to improve quality of life in these patients. Unfortunately, less than 5% of all patients with ESRD in India get renal transplants [3]. As availability of RRT is limited, options at prevention of renal deterioration must be explored. Evidence suggests that appropriate therapy aimed at controlling the common causes namely, diabetes and hypertension results in renal conservation and delays the need for RRT [1, 2]. Narula et al [4], in their article appearing in this issue, stress on conservative management of chronic renal failure.

Though RTx has been in practice in India for more than 3 decades, it has been grossly inadequate for Indian patients in terms of actual numbers, due to a shortage of resources and organs. Unlike most countries where cadaveric transplantation programme is very successful, in India less than 2% of RTx is based on brain dead heart beating cadaver donors [3]. The reasons for our cadaveric programme not taking off are many and complex. The most obvious ones are social and religious beliefs and taboos as well as the absence of a decision making process in the bereaved family. The other important factors are the near non-existence of networked organ tracking and retrieval organisations and the equivalent of transplant co-ordinators in India. The few successes seen in cadaver donation in India have been due more to the efforts of certain dedicated individuals rather than any organ retrieval and banking organisations in some Indian centres.

RTx is being performed practically in every major hospital in India, confirming the existence of a large pool of skilled and trained transplant teams. The bottleneck is the availability of organs. The living related donor programme suffers major setbacks. For example, only about three quarters of the patients obtain potential related donors of whom only two thirds are willing to donate and eventually only 35% of the eligible ESRD patients have related, willing and fit donors [5]. This underlines the sad and notorious aspect of the renal transplant programme in India, i.e. a vast majority of renal transplants are from non-related or paid live donors. Adverse publicity in the media led to the arrest of many members of ‘kidney cartels'. A fallout of this was a reduction in the number of RTx from 3600 in 2002 to about 2800 in 2003; with the trend continuing in subsequent years [6].

When it became known that many poor donors do not get even a nominal proportion of the amount a recipient pays to the cartel and that some of these donors do die [7], many ethical, some philosophical but very few practical solutions were offered by the scientific community [6, 7]. The provisions laid down in The Transplantation of Human Organs Act (1994) to prevent unrelated organ donation are either inadequate or the act lacks teeth. According to some authorities, one way of preventing illegal organ trafficking is to legalise payments for organ donations, thereby ensuring that the donors get their due [6, 8]. In order to discourage unrelated RTx and encourage live related donation, a case has been made for the use of marginal/ emotionally related donors in India [9, 10].

The situation of other organ transplants is no different in India. Our country has an enormous and ever increasing pool of patients with end stage liver disease for whom the only therapy available is liver transplantation [11]. In the absence of any other therapy, an overwhelming majority of them die and only a handful manages to get timely transplants. Though liver transplantation is technically very demanding, there are a large number of surgeons and other health care professionals trained in liver transplantation in India. However, this procedure is performed in only about 10 centres in India with their total experience amounting to about 250 liver transplants. Heart and lung transplantations, either individually or in combination, are being performed in India since the first successful heart transplant done in 1994, but their cumulative numbers can be counted on finger tips. The basic reason for these organ transplant procedures not taking off on a large scale is the absence of a viable cadaver donor programme. Evidence for this stems from the knowledge that a lion's share of liver grafts in Indian centres come from live relatives [12] and such live donation is not possible for heart and lung transplants, and hence their small numbers.

The first successful combined renal and pancreatic transplantation has recently been performed in India [13], though more than 800 such transplants are performed yearly in the USA alone. The obvious conclusion is that unless we have a viable cadaver transplant programme, we will stay routed to where we are now. When the world is rejoicing over the success of the first facial transplantation [14], Indians can only dream of it.

Bone marrow transplantation (BMT) and autologous stem cell transplantations are being increasingly performed in selected centres in India at present, with results comparable to those of the West [15]. The cost of this procedure in India is many times lower than that in the developed countries and more and more centres are now offering BMT and autologous stem cell transplantation to both the local population as well as medical tourists. This is clearly possible as these procedures are not dependent on cadaveric organs. All the arguments presented so far, emphasise the singular need for an active, cadaver-donor transplant programme in India.

The Armed Forces Medical Services (AFMS) has been offering its clientele all kinds of renal replacement therapy including renal transplants. Army Hospital (R&R) experience of 500 patients who underwent renal transplantation shows that our kidney graft survival rates are comparable to the best in the world (Varma PP 2006, personal communication, Nov 20). The same hospital offers BMT and plans are afoot to start liver transplant programme in that hospital and key personnel have been / are being trained in centres of excellence abroad. In addition, some of our haematopathologists are being trained in stem cell harvesting and culture. It is expected that the AFMS will offer their patients the state of the art organ transplants in the near future. One way of improving the outcomes following organ transplants would be to concentrate to establish fewer centres of excellence, rather than disperse resources to many centres.

A concern, however, lingers that the programme in AFMS also may eventually be jeopardised for want of adequate donors. To use bridge parlance, the only way out is to change the losing combination. There are three ways, as I visualise, to change the pitiable state of the cadaver transplant programme in this country. Firstly, the public needs to be educated, through all available means. Secondly, a dynamic and motivated organ retrieval apparatus should be established at the national level. Thirdly, the existing Human Organ Transplantation Act should be modified to plug the loop holes and to make ‘presumed consent'- unless otherwise explicitly stated- as the operating mode for organ retrieval from a brain dead cadaver.

In the meanwhile, just as Neemuch in Madhya Pradesh has shown the way for corneal donation, the Armed Forces should show the country how to run a successful cadaver transplant programme.

Organ Transplantation in India : Indian Scenario and Perspectives for the Armed Forces.

Objectives: Over the past three decades graft and pa­tient outcomes in kidney transplantation have improved dramatically. The aim of our study was to measure the prevalence of multiple artery renal transplants, and to analyze the rates of vascular and urologic complications in these recipients. Methods: Between July 1991 andAugust 2003 the trans­plantation team at our hospital performed 340 kidney transplantations. Twenty-nine patients (8.53%) who un­derwent multiple-artery anastomosis were compared with 311 patients (91.47%) with single-artery anastomosis. Of the 29 grafts with multiple arteries, 23 (79.3%) had dou­ble arteries and 5 (17.2%) had 3 arteries. The solitary patient with quadruple arteries (3.5%) underwent a suc­cessful double pyjama anastomosis. Postoperatively all patients were placed on immunosuppression and graft outcomes assessed. Results: Multiple vessel transplantation was attended by minimal postoperative complications. There was no significant different in graft function, assessed by the in­cidence of acute tubular necrosis (ATN) and post-trans­plantation hypertension. The patient survival rates were comparable and none of the patients who received multi­ple renal artery grafts developed vascular or urologic com­plications. Conclusions: Transplantation of kidneys with multiple renal arteries is generally avoided. However, shortage of organs continues to be critical. Our results confirm that multiple artery grafts can be successfully transplanted with results similar to single vessel kidney grafts.

P Madhusoodanan

Papers

Holmium : YAG Laser for Intra Corporeal Lithotripsy.

Intravesical Explosion during Transurethral Resection of Prostate – A Reminder

Urological complications of live related donor renal transplantation: 13 years' experience at a single center.

Organ Transplantation in India : Indian Scenario and Perspectives for the Armed Forces.

Multiple vessel renal transplant - army hospital (research and referral) experience