Medicine and Health Sciences Commons^™

Surgeons And Ethical Challenges In Operating Room, Nazim Syed Muhammad, Syed Shahabuddin

Section of Urology

Ethics lie in the heart of professionalism. In surgery, it represents an essential element, with surgeons facing ethical challenges in their routine practice. The rapid expansion of surgical technology and innovation along with the use of resources and consideration of conflict of interest have brought up the need for the development of current surgical code of ethics. Operating room represents a stressful environment where patients' lives depend upon careful preparation, planning and execution. The progression of surgery within the operating room must be done in harmony and in line with the ethical principles of autonomy, beneficence, non-maleficence and justice. Discussion …

What After Bcg Fails In Non-Muscle Invasive Bladder Cancer?, M Hammad Ather

Section of Urology

No abstract provided.

An Assessment Of The Impact Of Flow Disruptions On Mental Workload And Performance Of Surgeons During Percutaneous Nephrolithotomy, Sana Hussain, Syed Muhammad Nazim, Basit Salam, Nida Zahid, Hammad Ather

Section of Urology

Objective: The aim of this study was to assess the impact of intraoperative disruptions on surgeons’ workload and performance during percutaneous nephrolithotomy (PCNL).
Materials and methods: A structured and standardized tool was used to identify disruptions and interferences that occurred during 33 PCNL procedures. The surgical steps during PCNL were divided into four phases: ureteric catheter placement (phase I), puncture and tract dilation (phase II), intra-calyceal navigation and stone fragmentation (phase III), and tube placement (phase IV). Surgeons’ workload was evaluated using a validated tool: Surgery Task Load Index (SURG-TLX), and correlated with the mean observed intraoperative disruptions. All operating …

Analysis Of 114 Pedigrees Of Renal Stone Patients: A Retrospective Review, Syed Raziuddin Biyabani, Jamsheer Jehangir Talati, Daniya Umer, Zehra Kazmi, Hussam Uddin Soomro, Rubab Mansoor

Section of Urology

Background: Renal and ureteric stones (RS) can form due to genetic, metabolic, environmental, and diet-hydration related factors. Studies have shown that patients with family history (FH) of RS have higher likelihood of recurrence.
Materials and methods: We conducted a retrospective cross-sectional study on 114 pedigrees to investigate the impact of FH on recurrence of RS and examine patterns of inheritance. Results: Family history of renal stone disease was found in 42% of all patients. There was a significant increase of stone recurrence in RS patients with a positive FH (p=0.001). Seventy-one percent of patients with recurrent stones had at least …

Non-Invasive Predictors Of Response To Tamsulosin For Benign Prostatic Obstruction, Mohammad Shoaib, Muhibullah Bangash, Wajahat Aziz, Hammad Ather

Section of Urology

Objectives: To identify non-invasive predictors of response to tamsulosin 0.4 mg in patients with benign prostatic obstruction (BPO).
Methods: Males ≥ 50 years of age with lower urinary tract symptoms (LUTS) suggestive of BPO for over three months were included in the study. We assessed change in the mean International Prostate Symptom Score (IPSS) and maximum flow rate (Qmax) after six weeks of medical therapy. Clinical and uroflowmetry parameters were compared between two groups of patients with >25% vs. <25% change in the IPSS after treatment. Pre- and post-treatment post-void residue (PVR), Qmax, and IPSS were compared by independent t-test, univariate/multivariate regression analysis.
Results: A total of 121 patients were included. At presentation, the mean prostate size was 35.7±12.2 grams and the mean IPSS …

Simulation Based Team Training In Surgery - A Review, Syed Muhammad Nazim, Qamar Riaz

Section of Urology

The healthcare environment in surgery is complex, dynamic and often ambiguous. Besides subject knowledge and technical skills, other competencies, such as team work, communication skills and situation awareness, are required to ensure better patient-related outcome. Teams that demonstrate poor non-technical skills make more technical errors, often resulting in patient morbidity or mortality. Different hospital-based locations, such as operating rooms, intensive care units, emergency rooms and surgical wards, are the areas where poor team dynamics prevail. Simulation-based team training is a strategy to provide inter-professional training and experiential learning opportunities for surgeons, anaesthetists and allied health professionals. It helps them to …

The Correlation Between Stone Nephrolithometry Score And Hemoglobin Drop In Patients Undergoing Percutaneous Nephrolithotomy, Mohammad Shoaib, Muhibullah Bangash, Basit Salam, Hammad Ather

Section of Urology

Objective: In this study, we aimed to determine the correlation between the STONE score [(S)ize of the stone, (T)opography or location, degree of (O)bstruction of the urinary system, (N)umber of stones, and (E)valuation of Hounsfield units] and postoperative hemoglobin drop in patients undergoing percutaneous nephrolithotomy (PCNL).
Methods: This was a prospective observational study and all adult patients aged 18-65 years undergoing unilateral, single-tract PCNL using 26 Ch. Amplatz sheath for renal calculi were included. The five variables of the STONE nephrolithometry score were calculated prior to the procedure. The stone-free rates were assessed on imaging at four weeks and complications …

Nephron Sparing Surgery For Renal Tumors-Comparison Of Off-Clamp Partial Nephrectomy With Hilar Clamping, Imran K. Jalbani, Syed Muhammad Nazim, Maria Ahmed, Farhat Abbas

Section of Urology

Background and objective: Open partial nephrectomy (PN) is still considered gold standard procedure for T1 localized renal tumors. Conventional technique involves clamping of the renal artery with or without vein however, renal ischemia produces a certain level of damage to the kidneys. This study aims to investigate potential effect of off-clamp vs. hilar clamping PN on renal function.
Methods: This is a retrospective cohort study of patients who underwent unilateral, open partial nephrectomy for renal tumors b/w January 2009 December 2016 at our institution. A total of 90 partial nephrectomies were performed of which 65 cases were eligible for analysis. …

The Impact Of Post Pcnl Tube Type On Blood Loss And Postoperative Pain, Salman Jamil, Hammad Ather

Section of Urology

Objective: To evaluate the impact of nephrostomy tube type on postoperative pain and blood loss following percutaneous nephrolithotomy (PCNL).
Methods: This is a prospective non-randomized study performed at Aga Khan University Hospital from July 2017 to June 2018. In this study we prospectively studied adult patients (16 to 65 years) who underwent unilateral PCNL. Patients who had nephrostomy with balloon (12Fr Foley's catheter) were compared with patients who had nephrostomy without balloon (12Fr Nelaton™ catheter). STONE Nephrolithometry score was used to assess the stone complexity. Mean pain score at six and 24 hours and mean hemoglobin drop at 24 hours …

Iatrogenic Trauma Following Percutaneous And Minimally Invasive Surgical Interventions, M Hammad Ather, Tashfeen Ahmad, Shabbir Akhtar, Tabish Chawla, Aneela Darbar, Wardah Rafaqat, Syed Shahabuddin, Noman Shahzad, Shahid Ahmed Sami

Section of Urology

Technological progress has changed the landscape of surgical practice. Minimally invasive surgery (MIS) and percutaneous interventions (PC) are constantly replacing open procedures. This reduces hospital stay and allows quicker recovery. The application of MIS should follow the good medical practice dictum by Hippocrates i.e. "First do no harm". To remain abreast with new procedures, the medical personnel are required to update and enhance their knowledge and skill. To ensure safety, the innovations are rigorously tested and tried. The learning curve of MIS is shortened by simulator training and proctorship. Credentialing processes are in place to enhance safe delivery of care. …

Pheochromocytoma Associated With Von Hippel-Lindau Disease In A Pakistani Family, Imran K. Jalbani, Nazim Syed Muhammad, Farhat Abbas

Section of Urology

Objectives: The aim was to study the presentation, disease characteristics, operative outcome, and prognosis in patients with familial Pheochromocytoma associated with von Hippel-Lindau (VHL) disease.
Materials and Methods: There were six patients belonging to two generations of a single family who developed features of VHL over a period of 13 years and were treated at our institute. Patients' characteristics, that is, age, gender, presenting complaints and clinical signs, laboratory and biochemical evaluation, and the presence of associated conditions was gathered from medical records. The preoperative and postoperative radiological imaging and histopathological results were also collected.
Results: Out of six cases, …

Role Of Surgery In Locally Advanced Prostate Cancer, Nazim Syed Muhammad, Farhat Abbas

Section of Urology

A significant proportion of patients present with locally advanced prostate cancer with inherent higher risk of local recurrence and systemic relapse after initial treatment. Recent literature favors combination of radiation therapy and extended hormonal therapy for this subset of patients. The effectiveness of Radical prostatectomy (RP) alone for locally advanced prostate cancer is controversial and is a focus of debate. However, it can decrease the tumor burden and allows the accurate and precise pathological staging with the need for subsequent treatment. Comparison of RP and other treatment modalities is difficult and incorrect because of inherent selection bias. RP as a …

Hiv-1 Subtype A Gag Variability And Epitope Evolution, Syed Hani Abidi, Marcia L. Kalish, Farhat Abbas, Sarah Rowland-Jones, Syed Ali

Section of Urology

Objective: The aim of this study was to examine the course of time-dependent evolution of HIV-1 subtype A on a global level, especially with respect to the dynamics of immunogenic HIV gag epitopes.
Methods: We used a total of 1,893 HIV-1 subtype A gag sequences representing a timeline from 1985 through 2010, and 19 different countries in Africa, Europe and Asia. The phylogenetic relationship of subtype A gag and its epidemic dynamics was analysed through a Maximum Likelihood tree and Bayesian Skyline plot, genomic variability was measured in terms of G → A substitutions and Shannon entropy, and the time-dependent …

Surgical Management Of Pheochromocytoma In A 13-Week Pregnant Woman, Mazhar Ali Memon, Wajahat Aziz, Farhat Abbas

Section of Urology

A 34-year-old 13-week pregnant woman presented with hypertension refractory to medical therapy and on workup was found to have a right adrenal mass. Due to her persistent increased blood pressure she was advised urinary vanillylmandelic acid (VMA) and its level was raised. MRI of the abdomen showed a well-circumcised lesion in the right adrenal of 3.0×2.5 cm suggestive of pheochromocytoma. The patient was started on antihypertensives including α-blockers and β-blockers and planned for right open adrenalectomy. Intraoperatively, blood pressure was raised up to 180/110 mm Hg on slight manipulation of adrenal gland which was controlled with glyceryl-trinitrate and volatile agents. …

Promoter Hypermethylation Of Tumor Suppressor Genes Correlates With Tumor Grade And Invasiveness In Patients With Urothelial Bladder Cancer, Shumaila M. Bilgrami, Sohail A. Qureshi, Shahid Pervez, Farhat Abbas

Section of Urology

Purpose: To investigate the promoter methylation status at selected loci which encode for key proteins involved in apoptosis, DNA repair, cell cycle control and progression in urothelial cell carcinoma of bladder and compare the findings from tissue samples with that of plasma.
Methods: Total genomic DNA was isolated from 43 non-muscle invasive (low grade) and 33 muscle invasive (high grade) urothelial bladder cancer samples along with 10 control cases of normal bladder mucosa. Promoter methylation status was investigated for RASSF1A, APC, MGMT, CDKN2A and CDKN2B genes using real-time methylation-specific PCR with SYBR® green. Plasma samples from 16 patients with muscle …

Functional And Clinical Outcome Of Ileal (Studer) Neo-Bladder Reconstruction: Single Centre Experience From Pakistan, Syed M. Nazim, Muhammad Hammad Ather, Farhat Abbas

Section of Urology

Objective: To determine the medium and long-term outcome of orthotopic continent urinary diversion with ileal (Studer) neo-bladder following radical cystectomy. Study Design: Case series.
Place and Duration of Study: Department of Surgery, The Aga Khan University Hospital, Karachi, from January 1998 to September 2010.
Methodology: Thirty eight patients underwent radical cystectomy for invasive bladder tumor with ileal neo-bladder (Studer type) reconstruction. Peri-operative and late complications, functional outcome of neo-bladder, urinary continence, metabolic and upper urinary tract status and overall survival were evaluated in all patients.
Results: A total of 29 patients (23 males and 6 females) with mean age of …

Lifelong Learning: Established Concepts And Evolving Values, Jamsheer J Jehangir Talati Professor

Section of Urology

Objective: To summarise the concepts critical for understanding the content and value of lifelong learning (LL).
Methods: Ideas generated by personal experience were combined with those of philosophers, social scientists, educational institutions, governments and UNESCO, to facilitate an understanding of the importance of the basic concepts of LL.
Results: Autopoietic, continuous, self-determined, informal, vicarious, biographical, lifelong reflexive learning, from and for society, when supported by self-chosen formal courses, can build capacities and portable skills that allow useful responses to challenges and society’s new structures of governance. The need for LL is driven by challenges. LL flows continuously in pursuit of …

Attrition In Surgical Residency Programmes: Causes And Effects, Mehwash Nadeem, M Shahrukh Effendi, Muhammad Hammad Ather

Section of Urology

Objective: To determine the rate and trend of attrition from a surgical residency programme and to identify the reasons for attrition.
Methods: A questionnaire-based survey was conducted at a university hospital. Separate questionnaires were designed for residents and programme directors (PDs). The residents who left the training voluntarily from one of the five surgical residency programmes (i.e., general surgery, orthopaedics, neurosurgery, otorhinolaryngology and urology) during the academic years 2005-2011 were identified from a departmental database. The residents who did not respond after three attempts at contact, or those who refused to participate, were excluded.
Results: During the last 6years, 106 …

An Unusual Combination Of Extra-Adrenal Pheochromocytoma And Arteriovenous Malformation Of The Ureter In A Young Adult, Ali Khawaja, Wajahat Aziz, Syed Muhammad Nazim, Farhat Abbas

Section of Urology

We present a case of a 24-year-old gentleman who presented with painless pan haematuria for 2 weeks. During the workup, he was diagnosed to have a retrocaval mass after a CT scan while cystoscopy revealed a polypoidal pulsating lesion in the left ureter. After surgical manipulation of the retrocaval mass, the blood pressure of the patient raised to 260/130 mm Hg. It was completely resected and diagnosed as extra-adrenalpheochromocytoma (paraganglioma) after histopathology. The lesion in the ureter was completely excised and fulgurated and diagnosed as anarteriovenous malformation. To the best of our knowledge, this is the first patient to be …

Renal Arteriovenous Malformation: An Unusual Cause Of Recurrent Haematuria, Mazhar Ali, Wajahat Aziz, Farhat Abbas

Section of Urology

A 54-year-old woman presented with gross painless haematuria. Initial workup showed no abnormality except mild hydronephrosis on CT scan. Cystoscopy and retrograde pyelography did not find any gross lesion and her urine cytology was also negative. She had recurrent haematuria so her CT was reviewed with the radiologist with clinical suspicion of arteriovenous malformation (AVM) which was suggested by relatively increased contrast density in the hemiazygous vein and renal vein in the arterial phase. She underwent angioembiolisation of left renal AVM after which her haematuria settled.

Grading Complication Following Radical Cystectomy And Ileal Conduit For Bladder Cancer Using Clavien Grading System, Syed Johar Raza, M Hammad Ather, Faisal Aziz Khan, Zaheer Alam

Section of Urology

Objective: To determine the 30-day complication rate of radical cystectomy and urinary diversion using a validated system.
Study Design: An analytical descriptive study.
Place and Duration of Study: The Aga Khan University Hospital, Karachi, from 1990 to 2010.
Methodology: Patients who had undergone ileal conduit (IC) formation, following radical cystectomy (RC) for muscle invasive transitional cell carcinoma, were studied, using a prospectively maintained data base. Basic details were determined, complications were noted and graded according to the modified Clavien grading system (CG). Results were presented using descriptive statistics.
Results: Of all the RC performed at this hospital 89 patients received …

Triggers Of Blood Transfusion In Percutaneous Nephrolithotomy, Ali Akbar Zehri, Syed Raziuddin Biyabani, Khurram Muthair Siddiqui, Amanullah Memon

Section of Urology

Objective: To determine the triggers of blood transfusion in patients undergoing percutaneous nephrolithotomy (PCNL).
Study Design: Observational study.
Place and Duration of Study: The Aga Khan University Hospital, Karachi, from 1988 to 2007.
Methodology: The percutaneous surgery database was retrospectively reviewed to identify patients with postoperative haemorrhage and need for blood transfusion. Blood loss was estimated by the postoperative drop in haemoglobin factored by the quantity of any blood transfusion. Various patients and procedure-related factors were assessed for association with total blood loss or blood transfusion requirement using stepwise univariate, forward multivariate regression analysis.
Results: A total of 326 procedures …

Understanding The Context Of Balanced Scorecard Implementation: A Hospital-Based Case Study In Pakistan., F Rabbani, Sabrina Nh Lalji, Farhat Abbas, Sm Wasim Jafri, Junaid A. Razzak, Naheed Nabi, Firdous Jahan, Agha Ajmal, Max Petzold, Mats Brommels, Goran Tomson

Section of Urology

Background: As a response to a changing operating environment, healthcare administrators are implementing modern management tools in their organizations. The balanced scorecard (BSC) is considered a viable tool in high-income countries to improve hospital performance. The BSC has not been applied to hospital settings in low-income countries nor has the context for implementation been examined. This study explored contextual perspectives in relation to BSC implementation in a Pakistani hospital. Methods: Four clinical units of this hospital were involved in the BSC implementation based on their willingness to participate. Implementation included sensitization of units towards the BSC, developing specialty specific BSCs …

Primary Vesical Varices: A Cause Of Gross Haematuria, Fauzia Ahmad Bawany, Rajab Ali Ghirano, Syed Raziuddin Bayabani

Section of Urology

We report a case of isolated bladder varices that manifested with sudden onset, gross hematuria, in a 44-year-old male with no co-morbid conditions. Varicosities were discovered on cystoscopy. Conditions to look out for in such a situation are discussed.

Assessment, Surgeon, And Society, John Norcini, Jamsheer J Talati

Section of Urology

An increasing public demand to monitor and assure the quality of care provided by physicians and surgeons has been accompanied by a deepening appreciation within the profession of the demands of self-regulation and the need for accountability. To respond to these developments, the public and the profession have turned increasingly to assessment, both to establish initial competence and to ensure that it is maintained throughout a career. Fortunately, this comes at a time when there have been significant advances in the breadth and quality of the assessment tools available. This article provides an overview of the drivers of change in …

Silencing Of Mbd1 And Mecp2 In Prostate-Cancer-Derived Pc3 Cells Produces Differential Gene Expression Profiles And Cellular Phenotypes, Yaqinuddin Ahmed, Farhat Abbas, Syed S. Naqvi, Mohammad U. Bashir, Romena Qazi, Sohail A. Qureshi

Section of Urology

Alterations in genomic CpG methylation patterns have been found to be associated with cell transformation and neoplasia. Although it is recognized that methylation of CpG residues negatively regulates gene expression, how the various MBPs (methyl-binding proteins) contribute to this process remains elusive. To determine whether the two well characterized proteins MeCP2 (methyl-CpG-binding protein 2) and MBD1 (methyl-CpG-binding domain 1) have distinct or redundant functions, we employed RNAi (RNA interference) to silence their expression in the prostate cancer-derived PC3cell line, and subsequently compared cell growth, invasion and migration properties of these cell lines in addition to their respective mRNA-expressionprofiles. Cells devoid …

Down-Regulation Of Dnmt3b In Pc3 Cells Effects Locus-Specific Dna Methylation, And Represses Cellular Growth And Migration., Ahmed Yaqinuddin, Sohail A. Qureshi, Romena Qazi, Farhat Abbas

Section of Urology

BACKGROUND:

Aberrations in DNA methylation patterns promote changes in gene expression patterns and are invariably associated with neoplasia. DNA methylation is carried out and maintained by several DNA methyltransferases (DNMTs) among which DNMT1 functions as a maintenance methylase while DNMT3a and 3b serve as de novo enzymes. Although DNMT3b has been shown to preferentially target the methylationof DNA sequences residing in pericentric heterochromatin whether it is involved in gene specific methylation remains an open question. To address this issue, we have silenced the expression of DNMT3b in the prostate-derived PC3 cells through RNA interference and subsequently studied the accompanied cellular …

Correlation Of Three Immunohistochemically Detected Markers Of Neuroendocrine Differentiation With Clinical Predictors Of Disease Progression In Prostate Cancer, Hammad Ather, Farhat Abbas, Nuzhat Faruqui, Mohammad Israr, Shahid Pervez

Section of Urology

Background: The importance of immuno-histological detection of neuroendocrine differentiation in prostatic adenocarcinoma with respect to disease at presentation and Gleason grade is gaining acceptance. There is limited literature on the relative significance of three commonly used markers of NE differentiation i.e. Chromogranin A (CgA), Neuron specific enolase (NSE) and Synaptophysin (Syn). In the current work we have assessed the correlation of immuno-histological detection of neuroendocrine differentiation in prostatic adenocarcinoma with respect to disease at presentation and Gleason grade and to determine the relative value of various markers.
Materials and Methods: Consecutive samples of malignant prostatic specimens (Transurethral resection of prostate …

Mediastinal Parathyroid Adenoma Causing Primary Hyperparathyroidism, Farhat Abbas, Syed Raziuddin Biyabani, Amanullah Memon, Jamsheer Jehangir Talati

Section of Urology

An ectopically placed parathyroid adenoma in the anterior mediastinum is a rare cause of persistent or recurrent primary hyperparathyroidism (PHPT) and is recognized as an important cause of failed primary neck exploration. We encountered 3 such cases amongst 70 surgically treated patients with PHPT (4.3%) over a 20-year period. In 2 cases, the offending adenoma could be removed at first exploration whereas in the 3rd case, it was successfully removed with mediastinal exploration after 2 failed neck explorations. In established cases of PHPT with equivocal preoperative localization studies or negative neck explorations, an ectopically placed parathyroid adenoma should be considered …

Optimization Of Low Pre-Operative Hemoglobin Reduces Transfusion Requirement In Patients Undergoing Transurethral Resection Of Prostate, Hammad Ather, Nuzhat Faruqui, F. Abid

Section of Urology

Objective: To identify factors that influence peri-operative hemorrhage in view of reducing the need for transfusions in patients undergoing trans uretheral resection of prostate (TURP).
Methods: All patients undergoing TURP between January 1997 and December 1999 were identified using lCD 9CM coding and indexing system. Overall 430 patients were identified, however, 384 charts were included and reviewed for demographics, pre and intra-operative data and post-operative morbidity. Patients were divided into two groups on the basis of presence of significant hemorrhage.
Results: Overall 384 patients were analyzed. Nineteen patients had hemorrhage - group I whereas 365had no significant hemorrhage …