Currently I am an associate Professor of Urology at the Faculty of Medicine, Cairo University. My practice is ≈30% general urology and 70% a combination of kidney transplantation and urological oncology. In acquiring the surgical and clinical skills needed to be an efficient urological oncologist and kidney transplant surgeon, I pursued the kidney and pancreas transplant Fellowship at The Glickman Urological and Kidney Institute of the Cleveland Clinic (Ohio, USA). In my opinion this Fellowship is considered unique for several reasons. This is one of the very few kidney transplantation Fellowships in the USA that are mentored by urologists and geared towards urologists seeking training in kidney transplantation. This includes intensive training in multi-organ procurement techniques, exposing the Fellow to surgical fields and areas of the abdominal cavity that urologists might not be entirely familiar with, but would still need to master if a large right-sided renal mass with a vena caval thrombus is encountered. Liver mobilization and exposure of the retrohepatic vena cava (integral for successfully executing such a procedure) become common practice after performing a run of multi-organ procurements.
Moreover, the Fellowship includes extensive exposure to advanced minimally invasive laparoscopic procedures, i.e. laparoscopic donor nephrectomy. There is also a considerable volume of surgically challenging cases of RCC that allows the Fellow to use the aforementioned procurement techniques in these ‘maximally invasive’ procedures.
Pancreas transplantation can also be considered a natural development of kidney transplantation surgery. The surgical skills acquired in training for pancreas procurement, the actual transplant surgery, and postoperative care for pancreas recipients, provide a better understanding of the entire constellation of diabetes mellitus and the end-stage renal disease it causes.
Renovascular surgery is also an integral part of this Fellowship that trains in the treatment of nephrological patients. Despite most such patients being treated by percutaneous angioplasty and stenting, open surgery still has its place as another vital aspect of this comprehensive kind of training.
During the Fellowship I was able to work closely with a group of mentors from diverse academic backgrounds and interests, but the group was still very coherent. There is the urological kidney transplant group (David Goldfarb, Venk Krishnamurthi, Stuart Flechner, Daniel Shoskes, John Rabets, Charles Modlin and Alvin Wee) and the pancreas transplant group comprising Krishnamurthi, Rabets and Wee, who are all urologists, in addition to Charles Winans, who is a liver transplant surgeon. There is also a close working relationship with the vascular surgery group (Vic Kashyap) for the renal revascularization cases. Naturally the daily rounds with the transplant nephrologists (Richard Fatika, Brian Stephany and Emilio Poggio) were a constant learning experience. Thus, in the presence of these fine clinicians and surgeons, one can appreciate the quality of the training.
The duration of the Fellowship was 1 year (July 2008–June 2009) of intense and fulfilling surgical training. The Fellowship has matured over the years and has transformed into what could be termed a ‘Hybrid Fellowship’. Graduating Fellows will be able to perform a wide range of very difficult procedures after ‘fine tuning’ the surgical and clinical skills needed to perform multi-organ procurement, kidney and pancreas transplantation, and treat complex cases of RCC and renal revascularization, in addition to the challenging laparoscopic donor nephrectomy. Even if the graduating Fellows will not focus on kidney transplantation, but rather on urological oncology as the main subspeciality in their subsequent practice, they will still show the agility and efficiency needed in this equally demanding field.
The real initiator of such a Fellowship at the Urology Department of the Cleveland Clinic (currently The Glickman Urological and Kidney Institute) was the late Andrew Novick (1948–2008). Unfortunately he died during my Fellowship, but I could clearly appreciate his profound effect through all the staff with whom I worked. All of them had either completed their residencies or Fellowship with him. His contributions form the backbone of modern renal surgery. His vision of training a comprehensive kidney surgeon who is capable of treating surgical kidney disease, albeit renovascular disease, renal failure and RCC, is being realised, and I am proud to be a graduate of such a fine programme.