Table I: Endourological Procedures Performed at ZMKC

DISCUSSION

In this review, endo-urological procedures constituted 44.2% of the total urological procedures performed during the study period. This showcases the significant impact of endo-urological services in an active kidney transplant program. Endo-urology has a key role in the renal transplantation either in the pre-transplant patient or post kidney transplant patient. In many of the developed economies, endo-urology now has a role in kidney transplant itself as laparoscopic-assisted donor nephrectomies and robotic-assisted techniques are becoming increasingly popular.^17,18 These haven’t caught up in sub-Saharan Africa due to limitation in training and gadgetry to execute these minimal access techniques. Therefore, a kidney transplant program should be equipped with the necessary gadgetry and surgical skills to cater for such conditions when the need arises.

Cystoscopy and stent removal accounted for the majority of the endo-urological procedures carried out. This is not surprising as DJ stents are routinely left in place post-transplant to keep the neocystostomy patent, and has to be removed four weeks post-transplant via cystoscopy. Diagnostic cystoscopies were carried out on a few occasions in patients presenting with unexplained bladder outlet obstruction or frank haematuria before kidney transplantation. Cystoscopy and DJ stenting as a bridging therapy for patients presenting with deteriorating renal function in the phase of obstructive nephropathy from kidney stones before definitive therapy was carried out. The diagnostic and therapeutic cystoscopies were all carried out as day cases. The cystoscopies for DJ stents removal and those performed for diagnostic purposes were carried out under local anaesthesia. This makes local anaesthesia the most used anaesthesia in this series, being that cystoscopies for stent removal in post KT patients accounted for a greater proportion of endourological cases.

Benign prostatic hypertrophy (BPH) is a common cause of morbidity among men in middle and elderly age-group.¹⁴ Considering that a significant proportion of men with end-stage renal disease (ESRD) also fall into the same age-group, it is routine to elicit lower urinary tract symptoms in these patients following KT when their urine output increases from its pre-transplant level. Left unattended to, BPH has been significantly associated with renal allograft loss from back pressure effects on the renal allograft.¹⁹ There is evidence from longitudinal studies that BPH is a progressive disease.⁸ The transurethral resections of the prostate(TURP) done over this study period were on pre-KT patients, post-transplant patients and other men who had significant LUTS and a clear indication for prostatectomy. TURP pre-KT is associated with a significantly higher risk of intra and post-operative haemorrhage due to the impaired renal function hence requires a meticulous multi-disciplinary team approach in pre-operative preparation and post-operative management. This will include haemodialysis, with or without blood transfusion to optimize the patient and control of co-morbidities like hypertension and diabetes mellitus. There is controversy as to whether a surgical correction is more advantageous if performed before or after transplant. Some authors argue that if performed before transplant while the patient is still oliguric/anuric, bladder neck contracture or urethral scarring may develop.²⁰ On the other hand, if performed after transplant; one study reported a 25% incidence of major perioperative complications including death. In recent times and with the improvement in electro-cautery for TURP, the efficacy of TURP in the treatment of BOO after KT has been reportedly excellent in well-selected patients.²¹ Considering the risk of infection with immunosuppressants, several authors recommend performing TURP 6 to 8- weeks pre-transplant.⁸

In our centre, patients with symptomatic BPE are commenced on medical therapy especially alpha-1 adrenergic blockers pre transplant and followed-up post-transplant for worsening symptoms and subsequently offered TURP at least 12-week post-transplant if symptoms do not improve or other clear indications for prostatectomy.²²

Urolithiasis is also a common cause of obstructive nephropathy especially when they occur bilaterally or in a solitary kidney. Endourological procedures performed on patients with stone disease in this series include percutaneous nephrolithothomies (PCNL) and ureteroscopy and lithotripsy.²³ Stones in the lower and mid-ureter were approached in retrograde fashion by ureteroscopy and lithotripsy while kidney, renal pelvis and upper ureteric stones were accessed by PCNL. Two of the patients who had bilateral PCNLs with the hope of salvaging some renal function eventually required KT. The remaining PCNLs were performed on patients when indicated with upper urinary tract stones without kidney failure. None of the post-transplant patients required any form of stone surgery during the study period.

Image-guided procedures like percutaneous nephrostomies for urinary diversion in infected obstructed renal systems were performed in few patients while drainage of big renal cysts with/without adjuvant sclerotherapy was performed. Post-transplant complications like urine leaks with consequent urinomas and lymphoceles may require percutaneous drainage under ultrasound guidance to prevent secondary infection of these collections and its antecedent co-morbidity as similarly carried out by Gipson in his series of post KT patients.²⁴

CONCLUSION

An active kidney transplant program must be properly equipped and skilled for endo-urological procedures which have become critical in the management of these patients. Endoscopic removal of double j stents, TURPs and minimal access stone surgeries are some of the common endo-urological procedures performed with a good outcome. It is imperative for the modern urological surgeon in a KT program to possess endo-urological skills in this ever-changing terrain of medicine.

ACKNOWLEDGEMENT

We acknowledge the entire theatre staff at Zenith Medical and Kidney Centre, Abuja who provided the data from the hospital electronic media records for this manuscript.

CONFLICT OF INTEREST

There is no conflict of interest among the authors.

SOURCE OF FUNDING

There was no funding for this article

AUTHORS CONTRIBUTIONS

Drs Igbokwe and Abu were involved in the conceptualization and initial write-up of this paper. Drs Aremu and Igbokwe performed most of the endo-urological procedures. Dr Olatise supervised and made initial corrections to the manuscript. Dr Okafor retrieved and analysed the data from the records.