Sindh Institute Of Urology And Transplantation Research Articles

Incidence and risk factors of delirium in the intensive care unit of SIUT Karachi.

Objective: To estimate the incidence and risk factors of delirium in intensive care unit (ICU) of Sindh Institute of Urology and Transplantation (SIUT), Karachi. Study Design: Cross-sectional study. Setting: The ICU of SIUT, Karachi, Pakistan. Period: February 2023 to August, 2023. Methods: Patients over 18 years of age who were admitted to the ICU for more than 24 hours were analyzed. Patient with Richmond agitation sedation score (RASS >-2) were assessed for delirium using the confusion assessment method (CAM)-ICU method. Delirium subtypes were also evaluated. Domographic and clinical risk factors were evaluated for possible relationship with the existence of delirium. Results: Total 96 patient were enrolled in the study, 64 (66.7%) were male and 32 (33.3%) female. The mean age was 49.1±17.3 years. Mean RASS and CAM-ICU scores were 0.53±1.31 and 1.0±1.42 respectively. Delirium was present in 32 (33.3%) patients. It was noted that 45.4% patients had hypoactive delirium, 31.8% hyperactive delirium, and 22.7% mixed type. Patients aged 50 years or above had higher odds of delirium (OR: 0.41 [0.17-0.98], p=0.045), On multivariable regression model, BMI <25 Kg/m2, coexistence of ischemic heart disease and chronic kidney disease, patients with septic shock, post-operative patients, need of sedation were significantly associated with higher odds of delirium. Conclusion: Delirium is a frequent condition in ICU patients, with a higher occurrence of hypoactive delirium. The leading risk factors associated with delirium were older age, ischemic heart disease, chronic kidney disease and use of sedative drugs.

Maternal and fetal outcomes in pregnancy complicated by pre-existing lupus nephritis: Insights from a developing country Pakistan.

Pregnancy in women with systemic lupus erythematosus (SLE) has remained a great challenge for clinicians in terms of maternal and fetal outcomes. The outcomes in women with pre-existing lupus nephritis (LN) are variable. The impact of different classes of LN on maternal and fetal outcomes during pregnancy is not well defined, as data is very scarce, especially from the developing countries. A retrospective analysis was conducted on 52 women with 89 pregnancies. All had biopsy-proven LN. Those women who conceived at least 6months after the diagnosis were included. The analysis was conducted between July 1998 and June 2018 at Sindh Institute of Urology and Transplantation (SIUT), evaluating the outcomes for both the mother and the fetus with a minimum follow-up of 12months after child birth. The mean maternal age at SLE diagnosis was 21.45 ± 6years and at first pregnancy was 26.49 ± 5.63years. The mean disease duration was 14.02 ± 19.8months. At conception, 47 (52.8%) women were hypertensive, 9 (10%) had active disease while 38 (42.7%) and 42 (47.2%) were in complete and partial remission, respectively. A total of 17 (19.1%) were on mycophenolate mofetil (MMF), which was switched to azathioprine (AZA). Out of 89 pregnancies, 56 (62.9%) were successful, while 33 (37.07%) had fetal complications like spontaneous abortion, stillbirth, perinatal death, and intrauterine growth retardation (IUGR). There were more vaginal deliveries (33 [58.92%]) than caesarean sections (23 [41.07%]). Renal flare was observed in 33 (37.1%) women while 15 (16.9%) developed pre-eclampsia. Proliferative LN was found in 56 (62.9%) cases, but no significant differences were found in maternal and fetal outcomes in relation to LN classes (p = .58). However, disease outcomes at 12months were significantly poor in those with active disease at the time of conception (p < .05). There was only one maternal death. A total of 10 (11.2%) women showed deterioration in renal function and 5 (5.6%) were dialysis-dependent at 12months. The maternal and fetal outcomes in pre-existing LN depend on the disease activity at the time of conception. No correlation was found between International Society of Nephrology/Renal Pathology Society (ISN/RPS) classes of LN and adverse disease and pregnancy outcomes.

Accuracy of eGFR Equation for Predicting Glomeruloar Filtration Rate in Potential Living Kidney Donor

This Descriptive Cross-Sectional Study, involving 201 patients, conducted at Sindh Institute of Urology and Transplantation (SIUT) Karachi, Pakistan after approval from institute research board. The estimated Glomerular Filtration Rate (eGFR) was calculated using the appropriate equation. Participants were instructed to collect their urine over a 24-hour period in a container devoid of any additives or preservatives. The collected urine specimens were subsequently sent to the institutional laboratory for analysis, with GFR determined based on 24-hour urine creatinine clearance to ensure accuracy. All data collected during the study period were meticulously entered into a predefined proforma, which was then electronically stored and utilized for research purposes.&#x0D; Results: Mean ± SD of age was 33.30±9.12 years. Out of 201 patients, 124 (61.7%) were male while 77 (38.3%) were female. In distribution of accuracy of eGFR by CKD-EPI equation, accuracy of (Cr-Cys) equation was noted as 60 (29.9%), (Cys) as 47 (23.4%) while accuracy of CKD- EPI (PK) equation was documented as 96 (47.8%).&#x0D; Conclusion: It is to be concluded that accuracy of CKD-EPI is closer to 24 -h urinary creatinine clearance in the calculation of eGFR. However, none of the eGFR formulas can be used in renal transplant donors because of their low accuracy, and 24-h urine creatinine clearance should be used for evaluation of the GFR in this population.

Ascitic Fluid Lactate Level as a Predictor of Mortality in Cirrhotic Patients Having Spontaneous Bacterial Peritonitis (SBP).

Introduction Limited studies are available for predicting mortality in patients with spontaneous bacterial peritonitis (SBP) based on ascitic fluid analysis. Recently, a proposition has been made regarding the role of ascitic fluid lactate as a better prognostic indicator of mortality in cirrhotic patients with SBP. Therefore, we aimed to evaluate the utility of ascitic fluid lactate in predicting mortality in cirrhotic patients with SBP. Methods This was a prospective, observational study that was conducted in the Hepato-Gastroenterology Department of Sindh Institute of Urology and Transplantation (SIUT), Karachi from 1January2022 to 31December 2022.All the patients having liver cirrhosis with ascites, aged between 18 and 65 years, and presenting with fever and/or abdominal pain were recruited in the study in the first six months (i.e., from 1January 2022 to 30June 2022) and were followed for sixmore months for the outcome. However, those patients on dialysis or those with hepatocellular carcinoma,any other malignancy as per a history of solid organ transplant, a history of HIV infection, or thoseunderlying systemic sepsis or infections other than SBP were excluded from the study. The presence or absence of SBP was confirmed by doing the ascitic fluid analysis. Ascitic fluid lactate levels were also requested in each patient. Mortality was assessed at one, two, three, and six months, respectively. All the data were analyzed using SPSS version 23.0. The area under the receiver operating curve(AUROC) was obtained for ascitic fluid lactate for predicting mortality in SBP. At an optimal cutoff, the diagnostic accuracy of ascitic fluid lactate was obtained. Results The total number of cirrhotic patients included in the study was 123. The majority of the patients belong to Child Turcotte Pugh (CTP) class C (n = 88; 71%). Two third of the patients (65.8%; n = 81) had viral hepatitis i.e., hepatitis B, D, and/or C, as the cause of cirrhosis. Overall mortality was observed in 51(41.5%) patients. Ascitic fluid lactate was significantly raised in patients with SBP than in patients with non-SBP (p = 0.004). The AUROC of ascitic fluid lactate was highest at three months (AUROC = 0.88) followed by six months (AUROC = 0.84), two months (AUROC = 0.804), and one month (AUROC=0.773). At an optimal cut-off of more than or equal to 22.4 mg/dl, ascitic fluid lactate had a sensitivity of 84.9%, specificity of 85.7%, positive predictive value (PPV) of 97.3%, negative predictive value of 42.8% with diagnostic accuracy of 85% in predicting overall mortality in patients with SBP. On sub-analysis, the diagnostic accuracy of ascitic fluid lactate was highest at six months followed by at three, two, and one month, respectively. Conclusion Ascitic fluid lactate showed a good diagnostic utility in predicting the overall mortality in patients with SBP with the best diagnostic accuracy in predicting long-term (six months) mortality. However, further studies are required to validate our results.

Comparison of Outcomes of Extracorporeal Shockwave Lithotripsy with Ureteroscopic Lasertripsy for Management of Proximal Ureteral Stones.

To compare the outcomes of extracorporeal shockwave lithotripsy with ureterorenoscopy and lasertripsy for managing upper ureteral stones of size 10mm to 15mm. Observational, cross-sectional study. Place and Duration of the Study: Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), from December 2020 to December 2021. A total of 168 patients with the diagnosis of proximal ureteric stone of size 1-1.5 cm were enrolled for this study. Patients were divided into two groups by simple random method. Group 1 patients underwent ureteroscopic lithotripsy (URS) and lasertripsy while Group 2 patients were subjected to extracorporeal shockwave lithotripsy (ESWL). Patients' demography, operative time, duration of hospitalisation, complication rate and stone-free rates, were recorded for both groups. Frequency and percentages were calculated for categorical variables and mean and standard deviation were calculated for continuous variables. For comparison of continuous variables, one-way ANOVA was applied, and Chi-square test was applied to compare the categorical variables. The p-value ≤0.05 was taken as significant. The mean age was of 39.55 ± 14.06 years, with the majority falling within the age group of 26 to 40 years. There were more males (116, 69%) than females (52, 31%). Most of the patients did not have a history of diabetes or hypertension. Sixty-two patients had previous history of stones. The average duration of ureteric stone disease was 3.18 ± 3.14 months. The mean size of the ureteric stone was 10.82 ± 3.19mm. The procedure duration was significantly shorter for URS, as compared to ESWL (33.81 ± 15.42 minutes vs. 45.00 ± 0.00 minutes, p=<0.01. The overall stone clearance rate was significantly higher after URS (83.3%) as compared to ESWL (64.2%, p=0.05). URS was a superior treatment option as compared to ESWL. However, the selection of the most appropriate procedure should be based on a tailored approach considering the patient's preference and the size of the stones. Extracorporeal shockwave lithotripsy (ESWL), Ureteroscopic lithotripsy (URS), Modified clavien classification system (MCCS), Ureteric stone.

Correlation of lymphocyte subsets and inflammatory biomarkers with disease severity in COVID-19 patients.

To determine the correlation of lymphocyte subsets and soluble serum inflammatory biomarkers with disease severity in coronavirus disease-2019 infection. The retrospective study was conducted at the Department of Immunology, Sindh Institute of Urology and Transplantation (SIUI), Karachi, Pakistan from September 1 to November 30, 2021, and comprised data of patients admitted from June to July 2021 who tested positive for coronavirus disease-2019 on the basis of reverse transcription-polymerase chain reaction of nasopharyngeal swab specimens. The patients were categorised into severe group A and non-severe group B. Initial investigations included complete blood count, neutrophil-to-lymphocytes ratio, C-reactive protein, D-Dimers and serum ferritin levels. Lymphocyte subsets included cluster of differentiation-3+, cluster of differentiation-4+/ cluster of differentiation-3+, cluster of differentiation-8+ T lymphocytes, cluster of differentiation-19+B lymphocytes, cluster of differentiation-16+ cluster of differentiation-56+ Natural Killer cells and serum cytokine levels of interleukin-2, interleukin- 4, interleukin-6, interleukin-10, tumour necrosis factor-alpha and interferon gamma. They were correlated with disease severity. Data was analysed using SPSS 20. Of the 54 patients, 33(61.1%) were males and 21(38.9%) were females. There were 29(53.70%) patients in group A with median age 52 years (interquartile range: 43.5-65 years), and 25(46.29%) in group B with median age 50 years (interquartile range: 36.5-59 years) (p=0.241). Disease was significantly more severe in male patients compared to female (p=0.002). In group A, cluster of differentiation-3+ T cells were reduced in 21(72.4%) patients, cluster of differentiation-8+ T cells in 16(55.2%), cluster of differentiation-4+ T cells in 23(79.3%) and cluster of differentiation-19+ B cells in 8(27.6%). In group B, cluster of differentiation-3+ T cells were reduced in 10(40%) subjects, cluster of differentiation-8+ T cells in 7(28%), cluster of differentiation-4+ T cells in 12(48%) and cluster of differentiation-19+ B cells in 4(16%) patients. Serum cytokine levels were not significantly different between the groups (p>0.05). In group A, 7(24.13%) patients died, and in such cases, the neutrophil-to-lymphocytes ratio was significantly higher (p=0.037). Pro-inflammatory markers and cytokine levels increased, while lymphocyte subsets decreased with increasing severity of the disease.

Stone clearance rate in patients treated with open surgery versus percutaneous nephrolithotomy for the management of staghorn renal calculi.

Background: Urinary calculi, particularly staghorn renal calculi, pose a significant health challenge. Percutaneous nephrolithotomy (PCNL) and open surgery are two distinct surgical interventions employed for treating staghorn renal calculi. This study aimed to compare the stone clearance rates of patients undergoing open surgery versus percutaneous nephrolithotomy at the Department of Urology, Sindh Institute of Urology and Transplantation (SIUT) in Karachi, Pakistan. Methodology: A prospective cohort study was conducted from February 8th to August 7th, 2019. Patients aged 18 to 60 years, diagnosed with staghorn renal calculi, were included. Patients with other renal stones and untreated urinary tract infections were excluded. The study enrolled 230 patients, divided into two groups: Group I underwent percutaneous nephrolithotomies, and Group II underwent open surgery. Stone clearance was assessed through post-surgery X-ray KUB. Results: The mean age of participants was 44.99 years, with a balanced gender distribution. Both PCNL and open surgery achieved stone clearance rates of 68.7%, with significantly higher rates observed in the PCNL group (74.8% vs. 62.6%, p = 0.04). Stratification by age, gender, illness duration, and stone location did not yield substantial variations in stone clearance rates. Conclusion: PCNL demonstrated a superior stone clearance rate compared to open surgery in the treatment of staghorn renal calculi. This finding highlights the potential of PCNL as a more effective intervention for addressing this challenging urological condition.

Robotic-assisted surgery in Pakistan: its Pros and Cons

Dear Editor, Robotic surgery, is a state-of-the-art technique that enables surgeons to carry out complex procedures with greater accuracy. (1) The system's purpose was to assist surgeons in doing intricate operations while still doing laparoscopy. The system incorporates 3 basic components namely; is 1. Patient’s cart, with robotic arms.; 2. The vision cart incorporated with the hardware to run the system including the camera and the light controls;3. The surgeon’s console, a platform where surgeon controls the movements of the robotic arms. All three are linked by fiber optics. Telesurgery is possible, thanks to the network connection of the surgeon's console. This is how the first robotic surgery was performed, with the patient located in Strasbourg, France, and the surgeon doing the procedure located in the United States. (2) Clinical outcomes for robotic surgery are better than those for conventional laparoscopy; benefits include a lower complication rate, a shorter hospital stay, less post-operative pain, and better aesthetic results. The disadvantage is that training and a committed team are needed. The medical trolley is fairly heavy. The lack of tactile feedback to the surgeon is one of the main disadvantages of robotic surgery. The price of the system, including upkeep, is another barrier. (3) In Pakistan, the Sindh Government Qatar Hospital in Karachi hosted the first DVS system deployment in 2011. But after a few operations, this system did not show the promising outcome, most likely as a result of insufficient experience and technical support. In 2013, the second robotic platform (DVSi), which was more advanced and of a higher generation than the first, was placed in the Civil Hospital Karachi. (4) Surgical treatments were started in cooperation with the Sindh Institute of Urology and Transplantation (SIUT), which has performed over 500 operations to date. The effectiveness of this program has also been effectively aided by the Sindh government, which funds 150 cases each year. (5) A robotic platform costs about Rs 300 million, with the annual maintenance contract accounting for 10% of the total cost. The average price due to the sparse usage of tools (10 procedures) is around Rs. 529,310.571. (6,7) ---Continue

To Determine The Diagnostic Accuracy of Urinary Nuclear Matrix Protein 22 in Detection of Recurrence of TCC Bladder Among Patients Who Are on Active Surveillance By Taking Cystoscopic Biopsy As A Gold Standard

Objective: To determine the diagnostic accuracy of urinary nuclear matrix protein 22 in detection of recurrence of TCC bladder among patients who are on active surveillance by taking cystoscopic biopsy as a gold standard.&#x0D; Study Design: Cross-sectional study.Place and Duration of Study: Departments of Urology, Histopathology and Molecular Biology: Sindh Institute of Urology and Transplantation (SIUT), Karachi Pakistan, from Jan 2021 to Jun 2021.&#x0D; Methodology: Total 83 patients previously biopsy proven bladder carcinoma who are on active surveillance whether or not they have received intravesical chemotherapy were included in this study. All the information were noted into proforma, &#x0D; Results: The average age of the patients was 48.80±11.86 years. There were 46(55.42%) male and 37(44.58%) female. Sensitivity, specificity, PPV, NPV and accuracy of urinary nuclear matrix protein 22 was 88.9%, 80%, 93.3%, 69.6% and 86.7% resepctively.Practical implication: This study will help us to diagnose TCC bladder in early stages and to manage it in time sothat morbidity and mortality may be reduced.&#x0D; Conclusion: Measuring NMP22 level in the blood is a very important tool for detecting Tcc of the urinary bladder as it is much specific and sensitive test.

Standardised Uptake Value in Organ Confined Prostate Cancer in 68-Ga- Prostate-Specific Membrane Antigen Positron Emission Tomography-Computed Tomography Scan and its Correlation with Prostate Specific Antigen Level and Gleason Score.

A positron emission tomography (PET) scan and a computed tomography (CT) scan are an integral part of oncological imaging and other modalities such as magnetic resonance imaging, CT or bone scintigraphy have some limitations in staging the workup of prostate carcinoma. Combined with tissue-specific markers like prostate-specific membrane antigen (PSMA), positron emitter-based functional imaging results have improved. Our study aimed to determine the Standardised Uptake Value (SUVmax) in prostate adenocarcinoma that is confined to the organ in Ga-68-PSMA PET-CT scans and how it correlates with prostate-specific antigen (PSA) levels and Gleason score (GS). This cross-sectional study was conducted at Sindh Institute of Urology and Transplantation (SIUT), Karachi, and includes subjects referred for a Ga68-PSMA PET-CT scan from September 2017 to January 2022. Histopathologic-proven adenocarcinoma prostate patients with organ-confined disease and PSA levels obtained within 6 weeks before the PSMA-PET-CT scan were included in the study. PET-CT images were semi-quantitatively analysed by measuring SUVmax and the result was interpreted using statistical software SPSS version 22.0. A total of 154 patients were analysed. The mean age of patients was 66.57 ± 8.86 years. The GS of all patients ranges from 6 to 10. The mean and median PSA levels were 32.33 ng/mL (range: 0.004-306.00) and 14.20 ng/mL, respectively. The mean SUVmax of all prostatic lesions was 14.67 ± 12.58 and the median value was 10.76. SUVmax was higher in patients with a PSA level of more than ten than those with a <10. The correlation of SUVmax with PSA and GS showed a significant correlation. The SUVmax of organ-confined prostate cancer correlates well with PSA level and GS Median SUVmax and PSA directly relate to GS.

The Association of Weaning Outcome with Left Ventricular Diastolic Dysfunction in Critically Ill Patients

Objectives: The aim of this study is to investigate the correlation between left ventricular diastolic dysfunction and successful weaning from mechanical ventilation in patients who are critically ill. Methods: An observational study was conducted at the ICU of the Sindh Institute of Urology and Transplantation (SIUT) in Karachi from April 2022 to December 2022. Essential baseline features including age, gender, duration of hospital stay, and ICU admission were documented using a predetermined proforma. Throughout the spontaneous breathing trial (SBT), hemodynamic evaluation was performed and recorded. Furthermore, respiratory and echocardiography parameters during the SBT trial as well as weaning results were documented. Results: The research involved 103 participants, with the majority being male. Among the 40 individuals who had diastolic dysfunction, there was a noteworthy occurrence of weaning failure in 29 patients (72.5%) which was found to have statistical significance (p=0.004). Additionally, a significant correlation between LV diastolic dysfunction and in-hospital mortality (p=0.003) was discovered. In addition, an extended duration of mechanical ventilation exceeding five days significantly corresponded with LV diastolic dysfunction (p=0.007). Conclusion: The results of our study provide additional proof to reinforce the importance of left ventricular diastolic dysfunction in predicting weaning failure from mechanical ventilation. This discovery can help medical professionals understand better how monitoring a patient's cardiac function during weaning is crucial, particularly with critically ill individuals. By recognizing the significance of LV diastolic dysfunction in this context, doctors and nurses can take proactive measures to monitor and treat any potential issues. Keywords: Weaning outcome, Left ventricular diastolic dysfunction, critically ill patients

Augmentation Cystoplasty: Experience in the Developing World

ObjectiveTo assess functional outcomes and classify postoperative complications of augmentation cystoplasty by the Clavien-Dindo classification system.MethodsA total of 197 adult patients undergoing augmentation cystoplasty between January 2016 and December 2020 at the Department of Urology, Sindh Institute of Urology and Transplantation (SIUT), were included in the study after obtaining approval from the ethics review committee. Patients’ records were reviewed for assessment of complications up to 3 months of follow-up. Functional outcomes were assessed by comparing preoperative video urodynamics study (VUDS) findings with follow-up VUDS findings at 1 year. IBM SPSS v23 was used to record and analyze all the complications, treatments, and pre- and postoperative VUDS data.ResultsOf the 197 patients included in this study, 127 (64.5%) were male and 70 (35.5%) were female. The mean age of the patients was 38.4 ± 9.92 years. Eighty-seven patients (44.2%) remained complication-free, 64 patients (32.5%) had grade I-II complications, 44 patients (22.3%) had grade III and IV complications, and only 2 patients (1%) had grade V complications. Stomal stenosis was the most frequent complication, occurring in 14.7% of patients, followed by renal function deterioration and high-grade fever, each noted in 13.7% of patients. Mean preoperative bladder capacity was 144.3 ± 63.09 mL, mean preoperative filling pressure was 43.34 ± 26.92 cm3 H2O, while mean postoperative bladder capacity was 460.83 ± 70.69 mL and mean postoperative filling pressure was 7.47 ± 5.79 cm3 H2O.ConclusionAugmentation cystoplasty can increase bladder capacity and improve bladder function. Because of the potential for complications, it is essential to carefully choose patients for surgery and provide proper preoperative counseling. Additionally, it is crucial to give proactive postoperative care.

RESPONSE TO INTRADERMAL ROUTE OF HEPATITIS B VACCINATION IN CHILDREN ON MAINTENANCE HEMODIALYSIS: A SINGLE CENTER EXPERIENCE

Background: To determine the response of intradermal route of hepatitis B vaccine (HBV) in pediatric dialysis patients. Material and Methods: Prospective, observational study carried out in the Hemodialysis Unit, Sindh Institute of Urology and Transplantation (SIUT), Karachi, from October 2021 to September 2022.Patients younger than 18 years, Hepatitis B surface antigen negative irrespective of primary vaccination status, were tested for anti-Hepatitis B antibody titers. Those with levels less than 10IU/L were recruited for intradermal vaccination at 0,1 and 6 months and titers rechecked in the 2nd and 7th month of study. Results: Of the 168 children screened, 81 (48%) patients were eligible for vaccination, however, 52 agreed to participate. Males were 27 (52%). Mean age was 12.18± 2.61 years. End-stage kidney disease due to unknown etiology was the most common cause in 27 (52%) patients with mean dialysis duration being 1.43±1 years. Most, 48 (92%) patients were hypertensive and majority, 47 (90%) patients tested negative for hepatitis C. Final analysis was done on 38 patients. Thirty-four (89.4%) patients responded; 25 (65.8%) being good and excellent responders. Mean antibody titers before intradermal vaccination of 2.87±3 IU/L improved to 383±397 IU/L. Ages 11-15 years showed a statistically significant association with the development of anti-Hepatitis B antibody titers (p value: 0.02) while gender, dialysis duration, pre-vaccination HBs titers, hepatitis C status, hypertension and cause of end-stage kidney disease did not have any effect. Conclusion: ID route of HBV is efficacious in producing seroprotective anti-HBs titers in pediatric ESKD patients. Children 11-15 years had more robust response. Keywords: Children, Hemodialysis, Hepatitis B, Intradermal, Vaccination

Current status and challenges of robotic surgery in Pakistan.

Current status and challenges of robotic surgery in Pakistan.

Perspective Of Medical Ethical Practices in Health Care System of Pakistan

The obligations and duties of doctors, healthcare providers and hospitals towards patients, careers, and society are addressed by medical ethics.&#x0D; There are a number of bioethics that are specific to the medical field and that apply to various medical institutions and professional groups. The Hippocratic Oath that healthcare professionals must take when joining the medical fraternity contains the legal, ethical, and moral obligations of doctors1 Patients' rights (autonomy), resource equity, patient confidentiality, justice, non-maleficence, beneficence, patient safety, conflict of interests, ethics of privatization, informed consent, handling of the opposite sex, beginning and end of life, and healthcare team ethics are the main ethical issues and principles2. Medical workers are required to follow a set of fundamental, widely accepted medical ethical rules in the realm of health care. In underdeveloped nations, patient treatment frequently disregards bioethical standards and patient privacy.&#x0D; Although Pakistan Medical and Dental Council (PMDC) has its own code of medical ethics, there isn't much proof that it effectively polices ethical transgressions. In addition to flagrant violations of the code of conduct, it is frequently seen that informed permission, secrecy, and privacy are misused in "reasonable" ways3. At Pakistan's hospitals, both in the public and commercial sectors, there is insufficient adherence to ethical standards. Due to a lack of a strong system of monitoring and sanctions by the relevant Authorities, it is alleged that a lack of effective policy and regulation governing the ethical practice of medicine has a detrimental impact on the profession4&#x0D; These issues are against the international standards of medical ethics, and the sad reality is that people are paying with their lives for many of the unethical practices because of these issues. Medical ethics and guidelines have been mandated by PMC and PHC for decades to avoid contentious issues and to include biomedical ethics in medical practices and curricula. The National Bioethics Committee was established in January 2004 with the approval of the Pakistani government. It has between 20 and 21 members and is led by the Director General of Health at the Ministry of Health. In contrast, the Centre of Biomedical Ethics and Culture (CBEC), which was established in 2004 at SIUT (Sindh Institute of Urology and Transplantation) and is the first of its kind in Pakistan, offers Master's degrees in bioethics and promotes bioethical education, research, and training in Pakistan5

424.3: Trends of Antibiotic Resistance in E. Coli, Klebsiella Spp., Pseudomonas Aeruginosa and Enterococcus Spp. Urinary Tract Infection in Renal Transplant Recipients From Pakistan Over a Decade

Introduction: Antimicrobial resistance is a major public threat worldwide. There has been an emergence of multi-drug resistant (MDR) bacterial infections over the last decade. MDR Klebsiella species have become one of the most common nosocomial pathogens in hospitals. In Pakistan, many studies reported a rising trend of resistance to antimicrobials in clinical isolates of Klebsiella species (spp.), E-coli, Pseudomonas aeruginosa and Enterococcus spp. Solid-organ transplant (SOT) recipients are more prone to infections, particularly with MDR organisms due to immunocompromised status, multiple hospital visits, and increased exposure to antibiotics. There is a paucity of data on antibiotic susceptibility patterns among renal transplant recipients from Pakistan. This study is conducted to find the trends in antimicrobial resistance patterns among common organisms isolated in the urinary tract over a 10-year period in renal transplant recipients. The aim is to guide the physicians regarding decisions over empirical antimicrobial choices. Methods: Sindh Institute of Urology and Transplantation (SIUT) is a 700-bedded tertiary care hospital in Karachi, Pakistan. It has had a comprehensive renal transplantation program with more than 6500 transplantations now. A retrospective computerized data review of urine cultures from renal transplant recipients in 2010 and 2020 was conducted. The trend of E.coli, Klebsiella species (spp.) Pseudomonas aeruginosa and Enterococcus spp. were collected. The resistance pattern of amoxicillin-clavulanic acid, ceftriaxone (ceftazidime for Pseudomonas aeurginosa), piperacillin-tazobactam, ciprofloxacin, amikacin, co-trimoxazole, and imipenem were compared over the 10 years period. Results: A total of 2,088 out of 6,249 (33%) and 2902 out of 8,115 (36%) urine cultures were positive in 2010 and 2020 respectively. The most common organisms isolated and their trend in the last decade is shown in figure 1.Over the decade, E-coli strains become 100% resistant to ciprofloxacin, ceftriaxone resistance has increased to 80%, and imipenem to 11%. In Klebsiella spp. imipenem resistance has increased to 19%. There is no significant change in the resistance pattern among Pseudomonas aeurginosa. Regarding Enterococcus spp. there is a rise in vancomycin resistance over the decade from 13% to 17% (Figure 2).Conclusion: Resistance to broad-spectrum antimicrobials has been increased with a>10% increase in carbapenems resistance over the last 10 years. E-coli has particularly become more resistant over the decade. We are also seeing more vancomycin-resistant enterococcus. The alarming increase in resistance may lead to increased morbidity in renal transplant recipients because we are left with only injectable options. We need a robust stewardship program for judicious use of antimicrobials and better infection control measures to contain increasing resistance.

P8.016: Gram Negative Blood Stream Infection in Renal Transplant Recipients: Risk Factors and Outcome From a Transplant Center in Pakistan

Background: Gram-negative bacteremia (GNB) is a common cause of bloodstream infection in renal transplant recipients (RTR). The risk factors are cytomegalovirus infection (CMV), pre-transplant dialysis, acute rejection, urological abnormalities, and ureteral stent. The mortality rate is 2.5 to 11%. Considering the huge impact on morbidity and mortality, our aim is to analyze the characteristics and outcomes of GNB in RTRs. Methods: A case-control study at Sindh Institute of Urology and Transplantation (SIUT), Karachi, Pakistan. The files of all renal transplant recipients who had documented GNB from January 2015 to December 2017 were reviewed till December 2020. The controls were matched with age, sex, and date of transplant. The first episode of GNB was taken. Clinical features, received anti-thymocyte globulin (ATG) or solumederol and cytomegalovirus infection (CMV) 90 days pre or post bacteremia, recurrent urinary tract infections (UTI), source of bacteremia and microbiology, all-cause mortality at day 28 and graft function at the last follow up were noted. Results: Out of 1009 RTR, 33 (3.3%) episodes of GNB occurred. The mean age was 30±11.85years, 61% males. Around 48% developed bacteremia within 6 months post-transplant. The most common source was UTI (75.8%). Fever in 48% and only 39% had leukocytosis. Around 9% were admitted in the intensive care unit. E-coli was the most common organism (70%) (Table 1). Stone disease at the time of transplant was significantly associated with bacteremia (p=0.029). There was no difference in receiving ATG or solumeredol and CMV before bacteremia. A significant number of patients received solumeredol for rejection (p=0.035) and had CMV (p=0.044) within 90 days after bacteremia. Recurrent UTI is significantly associated with bacteremia (p<0.001). The graft function at the last follow-up (2 years) was significantly deranged in patients with bacteremia (p=0.0001). Conclusion: Gram-negative bacteremia was found in 3% of RTR and half of them developed within 6 months post-transplant. UTI was the most common source and recurrent UTI was significantly associated with bacteremia. The stone disease was the most significant risk factor. Patients develop rejection and CMV infection within 3 months post bacteremia. There was a significant graft dysfunction among patients with bacteremia at a mean follow-up of 2 years. We need to focus on the management of recurrent UTIs to prevent bacteremia and graft dysfunction in renal transplant recipients.

A Tertiary Care Center's Experience with Clinicopathological Characteristics of Gallbladder Carcinoma in Our Population.

IntroductionGallbladder cancer (GBC) is the most common malignant biliary tract tumor with the shortest survival from the time of diagnosis. This poor prognosis is due to the destructive biologic behavior of GBC, lack of sensitive screening tests for early detection, and vague nature of first presentation. Here in this study, we will evaluate the baseline characteristics of the patients presenting with gallbladder carcinoma in our population.Materials and methodsThis retrospective study was conducted in the Department of Gastroenterology at Sindh Institute of Urology and Transplantation (SIUT), Karachi. Patient data were compiled and composed from the in-patient health records, radiology, and operational records. Those patients with suspicion of GBC, but negative at histology, or patients having inconclusive radiologic findings, were excluded. Baseline characteristics were recorded. Results were presented as means ± SD for quantitative data or as numbers with percentages for qualitative data. Continuous variables were analyzed using the Student's t-test, while categorical variables were analyzed using the Chi-square test. A p-value of <0.05 was considered statistically significant.ResultsA total of 162 patients were included in our study. Among them, 101 (62.3%) were females. Hypertension was the most common comorbid illness noted in 29 (17.9%) patients while 91 (56.2%) patients had no concurrent comorbidities. Most common risk factor for carcinoma of gallbladder was gallstones seen in 106 (65.1%) patients. The most common presenting complaint was combination of obstructive jaundice, weight loss with right hypochondrial pain seen in 66 (40.7%) patients. On CT abdomen, direct liver infiltration without lymphovascular invasion was noted in 77 (47.5%) patients followed by liver infiltration along with lymphovascular invasion in 26 (16%) patients and distant metastasis in 24 (14.8%) patients. On gallbladder (GB) mass biopsy, 58 (35.8%) patients had well-differentiated, 46 (28.4%) had moderately differentiated, while 33 (20.4%) had poorly differentiated adenocarcinoma. Of 162 patients, 103 (63.6%) patients underwent endoscopic retrograde cholangiopancreatography (ERCP). The most common finding on ERCP was proximal common bile duct (CBD) stricture with intrahepatic biliary system dilatation which was noted in 95 (58.6%) patients. Percutaneous transhepatic cholangiography (PTC) was performed only in 9 (5.6%) patients. Seventeen (10.5%) patients were managed by simple cholecystectomy, 39 (24.1%) patients underwent extended cholecystectomy, 14 (8.6%) patients underwent chemotherapy, while 102 (56.8%) patients were given palliative management. When followed for 1 year, 101 (62.3%) patients died within 6 months.ConclusionThe baseline characteristics, biopsy findings, modes of treatment, and rates of 1 year mortality were studied in patients with gallbladder carcinoma in our population. Advanced age, high white blood cell counts, and serum bilirubin at presentation with low lymphocyte count and presence of comorbid illnesses were the factors independently associated with increased mortality in patients with gallbladder carcinoma. However, further studies with large sample size and stratification with respect to age, gender, and different variables can be done in terms of mortality in patients with gallbladder carcinoma.How to cite this articleAkbar N, Yaseen T, Muhammad A, et al. A Tertiary Care Center's Experience with Clinicopathological Characteristics of Gallbladder Carcinoma in Our Population. Euroasian J Hepato-Gastroenterol 2022;12(1):35–39.

Augmentation Cystoplasty in Adult Patients with Renal Impairment.

Bladder augmentation is beneficial in patients with neurogenic bladder due to spinal cord injury, multiple sclerosis, and tuberculous bladder. This retrospective study was done to determine the outcome of augmentation cystoplasty in adult patients with renal dysfunction. The study was done at the Sindh Institute of Urology and Transplantation (SIUT), Karachi from January 2010 till December 2019. A total of 153 patients underwent augmentation cystoplasty. Among these, 28 patients met the inclusion criteria of adult patients with age >18 years, and renal impairment at the time of the procedure. Exclusion criteria were patients with normal renal functions. Out of 28 patients, 17 (60%) showed improvement in renal functions post-augmentation cystoplasty, while 2 (7.14%) deteriorated and 9 (32.13%) patients showed static function in the same chronic kidney disease stages. Results from this study showed that augmentation cystoplasty is a safe operative procedure even in renal failure patients. It leads to improvement in renal functions in a significant number of patients. Key Words: Adults, Augmentation cystoplasty, Renal failure, Bladder compliance.

Transition from da Vinci to Versius robotic surgical system: initial experience and outcomes of over 100 consecutive procedures.

We sought to describe the development of the robotic urology program at Sindh Institute of Urology and Transplantation (SIUT) and the feasibility of transitioning from the da Vinci to Versius robotic systems. The SIUT robotics program began in 2017 utilizing the da Vinci Si robotic system, transitioning to the Versius system in 2021. Retrospective review of our quality assurance database was performed. All procedures performed utilizing the two systems were identified, analyzed, and compared. Data were described with descriptive statistics. Matched procedures (by type of procedure) performed by the same surgeons utilizing the da Vinci and Versius were compared. All tests were double-sided with statistical significance set at p < 0.05.106 cases were performed by the Versius robotic surgical system in 2021. Median age was 42years (IQR 26-56), and 69 (65%) were males. Procedures included both benign (83%) and malignant disorders (17%), several upper tract (75%), and pelvic/lower tract (25%). No major intraoperative complications were observed. Conversion to open occurred in six procedures. Malfunction of the robotic arms occurred in two procedures: the erroneous bedside units (BSU) were replaced. Eight patients developed postoperative high-grade complications. Matched analysis of various procedures (pyeloplasty, stone surgery, radical, partial, and simple nephrectomy) showed no significant difference in perioperative outcomes. To our knowledge, this is the first and largest series of urologic procedures performed by the Versius robotic surgical system.