Com ment
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with essential the Noticeand printed on the inside back cover.should Tablesbeand figures should be included only if absolutely no more than five references given.
Urological complications of renal transplantation: the impact of double J ureteric stents We read the above article with interest (Annals, September 1991, vol 73, p316). The authors have emphasised the role of double J (DJ) stents in the prevention and management of ureteric complications after renal transplantation. They recommend reopening the cystostomy and placing the DJ stent surgically. We find this unnecessary because a DJ stent can better be positioned cystoscopically under local/regional or general anaesthesia. One has to realise that the ureter of a transplanted kidney is usually tortuous and is unsupported by periureteral tissues as compared to native ureter. Hence any forceful and/or blind retrograde manipulation may be hazardous. We first instill some contrast in to the ureter retrogradely to delineate its anatomy and then gently pass the flexible portion of the movable core 0.038 or 0.035 guidewire. The length of flexible portion can be adjusted as per the need. Having navigated the ureteral curves using the flexible portion, the movable core is advanced to stiffen the guidewire and the ureter is thus straightened. The Dl stent can be easily slid over this stiff guidewire. The success rate of such a method is more provided the operator has experience in endourology. The authors also need to clarify the site of leakages mentioned in the text and Table III. While the text on page 317 mentions the distribution of site as UVJ, midureteric and upper ureteric; the table mentions three pelvic leaks. One case of pelvic leak (Table III, case no. 7) has been managed by ureterovesical anastomosis. We fail to understand why a revision reimplantation was performed when the leakage site was high up. One possible reason, not mentioned in the article, could be associated UVJ obstruction leading to pelvic leak, but we do not find mention of the 36-year-old male in Table IV under ureteric obstructions. Two cases of PUJ obstruction have also been managed by 1-2 weeks of stenting via a cystotomy. We would like to know what was the cause of PUJ obstruction and what was the further follow-up of these cases after removal of the DJ stents. DR DALELA M BHANDARI MCh MNAMS Professor and Chairman Department of Urology & Renal Transplantation Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, India
Author's reply I welcome the opportunity to respond to the points raised by Drs Dalela and Bhandari. There is often more than one way to correctly manage a particular clinical problem and the point of my paper was to highlight the techniques that worked in Leicester. The method described by Drs Dalela and Bhandari is an interesting alternative to open surgery in the treatment of ureteric obstruction, but it does sound technically difficult and it would have been interesting to see some figures relating to their success rate. I do not, however, believe that their technique has much of a role in the management of urine leaks, which may be associated with ureteric necrosis and need to be treated by early re-exploration of the transplant.
In Case 7 (Table III, p 318) leakage from the renal pelvis was associated with a rather ischaemic appearance at the ureterovesical junction and this was the reason for re-implantation of the ureter. Finally, the cause of the two cases of PUJ obstruction were unknown. In both cases there was no recurrence of obstruction at follow-up periods in excess of 1 year. MICHAEL NICHOLSON MD FRCS Senior Registrar Oxford Transplant Centre Headington, Oxford
Combined surgical audit by microcomputer involving units in four health regions It was with interest that we read a further report on the use of computer-held data for the purposes of comparing surgical units (Annals, January 1992, vol 74, p47). The efficiency that this method of data handling confers on the important process of comparative studies warrants that as a method of audit it receives full evaluation. The authors do address the limitations of such global appraisals of surgical workload, and in this regard we agree (1). However, the authors' response to the dilemma of refining the comparisons was to return to the subjective and threatening arena of the surgical audit meeting. An alternative approach is to develop and validate formulas for standardising case mix, manpower and resource (2). Outcome measures using defined endpoints such as symptom profiles and quality of life indices need to become incorporated into the data. Mailshot facilities already exist on many of the surgical management systems which would enable patient-defined post-discharge information to become incorporated into such studies. Once these instruments exist questions concerned with variations in health care can be addressed. MARK EMBERTON FRCS Research Fellow
Audit Unit Royal College of Surgeons of England BRIAN W ELLIS FRCS Consultant Surgeon
Ashford Hospital Middlesex
References I Emberton M, Rivett R, Ellis BWE. Comparative audit-a new method of audit delivery. Ann R Coll Surg Engl 1991;73(6)Suppl: 117-120. 2 Collins CD, Jones SM. Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload. Br Med J 1990;301:324-5.
Bupivacaine instillation after herniorrhaphy The authors' conclusion that instillation of bupivacaine reduces pain after herniorrhaphy is unwarranted (Annals, March 1992, vol 74, p85). In their small series of 50 cases they showed only that it was no different from a field block and as there was no
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with essential the Noticeand printed on the inside back cover.should Tablesbeand figures should be included only if absolutely no more than five references given.
Urological complications of renal transplantation: the impact of double J ureteric stents We read the above article with interest (Annals, September 1991, vol 73, p316). The authors have emphasised the role of double J (DJ) stents in the prevention and management of ureteric complications after renal transplantation. They recommend reopening the cystostomy and placing the DJ stent surgically. We find this unnecessary because a DJ stent can better be positioned cystoscopically under local/regional or general anaesthesia. One has to realise that the ureter of a transplanted kidney is usually tortuous and is unsupported by periureteral tissues as compared to native ureter. Hence any forceful and/or blind retrograde manipulation may be hazardous. We first instill some contrast in to the ureter retrogradely to delineate its anatomy and then gently pass the flexible portion of the movable core 0.038 or 0.035 guidewire. The length of flexible portion can be adjusted as per the need. Having navigated the ureteral curves using the flexible portion, the movable core is advanced to stiffen the guidewire and the ureter is thus straightened. The Dl stent can be easily slid over this stiff guidewire. The success rate of such a method is more provided the operator has experience in endourology. The authors also need to clarify the site of leakages mentioned in the text and Table III. While the text on page 317 mentions the distribution of site as UVJ, midureteric and upper ureteric; the table mentions three pelvic leaks. One case of pelvic leak (Table III, case no. 7) has been managed by ureterovesical anastomosis. We fail to understand why a revision reimplantation was performed when the leakage site was high up. One possible reason, not mentioned in the article, could be associated UVJ obstruction leading to pelvic leak, but we do not find mention of the 36-year-old male in Table IV under ureteric obstructions. Two cases of PUJ obstruction have also been managed by 1-2 weeks of stenting via a cystotomy. We would like to know what was the cause of PUJ obstruction and what was the further follow-up of these cases after removal of the DJ stents. DR DALELA M BHANDARI MCh MNAMS Professor and Chairman Department of Urology & Renal Transplantation Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, India
Author's reply I welcome the opportunity to respond to the points raised by Drs Dalela and Bhandari. There is often more than one way to correctly manage a particular clinical problem and the point of my paper was to highlight the techniques that worked in Leicester. The method described by Drs Dalela and Bhandari is an interesting alternative to open surgery in the treatment of ureteric obstruction, but it does sound technically difficult and it would have been interesting to see some figures relating to their success rate. I do not, however, believe that their technique has much of a role in the management of urine leaks, which may be associated with ureteric necrosis and need to be treated by early re-exploration of the transplant.
In Case 7 (Table III, p 318) leakage from the renal pelvis was associated with a rather ischaemic appearance at the ureterovesical junction and this was the reason for re-implantation of the ureter. Finally, the cause of the two cases of PUJ obstruction were unknown. In both cases there was no recurrence of obstruction at follow-up periods in excess of 1 year. MICHAEL NICHOLSON MD FRCS Senior Registrar Oxford Transplant Centre Headington, Oxford
Combined surgical audit by microcomputer involving units in four health regions It was with interest that we read a further report on the use of computer-held data for the purposes of comparing surgical units (Annals, January 1992, vol 74, p47). The efficiency that this method of data handling confers on the important process of comparative studies warrants that as a method of audit it receives full evaluation. The authors do address the limitations of such global appraisals of surgical workload, and in this regard we agree (1). However, the authors' response to the dilemma of refining the comparisons was to return to the subjective and threatening arena of the surgical audit meeting. An alternative approach is to develop and validate formulas for standardising case mix, manpower and resource (2). Outcome measures using defined endpoints such as symptom profiles and quality of life indices need to become incorporated into the data. Mailshot facilities already exist on many of the surgical management systems which would enable patient-defined post-discharge information to become incorporated into such studies. Once these instruments exist questions concerned with variations in health care can be addressed. MARK EMBERTON FRCS Research Fellow
Audit Unit Royal College of Surgeons of England BRIAN W ELLIS FRCS Consultant Surgeon
Ashford Hospital Middlesex
References I Emberton M, Rivett R, Ellis BWE. Comparative audit-a new method of audit delivery. Ann R Coll Surg Engl 1991;73(6)Suppl: 117-120. 2 Collins CD, Jones SM. Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload. Br Med J 1990;301:324-5.
Bupivacaine instillation after herniorrhaphy The authors' conclusion that instillation of bupivacaine reduces pain after herniorrhaphy is unwarranted (Annals, March 1992, vol 74, p85). In their small series of 50 cases they showed only that it was no different from a field block and as there was no
