Monday, July 18, 2011

Laparoscopic partial cystectomy for the urachal cyst




A 25 year old lady was diagnosed to be a case of urachal cyst after cystoscopic biopsy.The mass was cystic situtaed on left dome of the bladder.She was taken up for laparoscopic surgery.The mass along with adjacent detrusor muscle(detrusor myectomy) with urachal ligament were taken down and removed in toto.The patient is doing well and polanned for discharge on 3rd post-operative period.

Retrocaval ureter: a rare anamoly presenting with pain



A 23 year old patient presented with pain in right flank on and off for more than 3 months duration.He was investigated with ultrasound of KUB region which revealed right sided moderate hydronephrosis with prominent upper ureter.He underwent IVP which showed right moderate hydronephrosis with kinked upper ureter.He was taken up for CT scan for further demonstration of the anamoly which showed retrocaval ureter.The DTPA scan revealed left obstructed system.The patient is planned for laparoscopic uretero-ureterostomy.

PCNL in a partial staghorn calculus

A 50 year lady was taken up for PCNL for left partial staghorn calculus.She was a diabetic patient and had a obese body predisposition.


She was taken up for PCNL ; with two punctures one in mid-posterior calyx and the other one in the lower anterior calyx.Near complete clerance was given The plan is to perform a secondary RIRS after a period of 3 weeks for any residula calculi.

PCNL in a complete staghorn calculus

A 40 year old lady presented to us with flank pain on left side on and off for a period of 6 months.On investigations she was found to have calculus -a complete staghorn variety in the left renal pelvis.
She was taken up for PCNL.A total of 4 punctures in different calyces had to be made.The surgery was carried out in 3 sessions.At the end we could give a complete endoscopic and fluoroscopic clearance.

Wednesday, July 6, 2011

Interstitial cystitis/Painful bladder syndrome: A review

A 45 year old lady came to us with recurrent complaints of pain while passing urine,suprapubic discomfort,urgency lasting for more than 1 years.She had been investigated extensively and was given antibiotics/bladder spasmolytics/antimuscarinic agents/NSAIDs with no relief.Her all the investigations were normal.She was taken up for cystoscopy which revealed bladder capacity of 250 ml with glomerulations on emptying the bladder.The bladder biopsy was done after a therapeutic distension for 8-10 minutes.The patient was started on amitryptiline,Comfora(sodium pentosan polysulphate 100 mg three times a day)and gabapentin(TRIPLE THERAPY).She had temporary remission after the institution of the therapy and now relatively free of the symptoms.We are planning to repeat the distension after a period of 6 months.

REVIEW OF LITERATURE:
The interstitial cystitis is a chronic condition which comprimses of a constellation of symptoms-bladder pain, suprapubic/pelvic pressure, urgency, dysuria etc. The all above symptoms may occur together or the patient may suffer each one of them in isolation.
This is diagnosis of exclusion and requires a high level of suspicion on the part of the treating urologist. Any patient having unexplained irritative bladder symptoms without relief and the all investigations showing no culprit then we must doubt painful bladder syndrome.
The condition has been seen as debility because its effect on patients quality of life. A Harvard medical scholl guide states that the impact of this condition on the patient can be compared with chronic cancer pain /or renal dialysis.
The International Continence Society (ICS) reserves the diagnosis of IC for patients with “typical cystoscopic and histological features,” without further specifying these. In the absence of clear criteria for “IC,” this chapter will refer to PBS/IC and IC interchangeably, because all but recent literature terms the syndrome “IC.”(Campbells Book of Urology)
National Institute of Diabetes and kidney Diseases(NIDDK) diagnostic criteria:It’s a cystoscopic and histological diagnosis.Cystoscopy should demonstrate glomerulations(with or without Hunners ulcer)-diffuse on distension of bladder.

There are some conditions which must be excluded:-UTI/vaginitis/prostatitis
-Urinary tuberculosis
-Stone disease
-Radiation/cyclophosphamide cystitis
-malignancy
-herpetic affections(less than 3 months duration)
-urethral instrumentation(recent)
-stricture urethra
Urodynamically-the pain should be elicited after filling the bladder for 100-150 ml and the capacity should not be more than 350 ml.There should be any presence of uninhibited bladder contractions.
The typically age of the patient should be more than 18 years and the symptoms should be present for more than 9 months. There should not be a relief on institution of anticholinergics /antibiotics.
A patient who fulfills these criteria can be termed to be a patient of interstitial cystitis.
This condition is more common in women especially menopausal women. Although all the people irrespective of age, socioeconomic status, menopausal status do suffer from this syndrome.

The patient of IC/PBS may have associated illnesses like-allergic conditions,Inflammatory bowel diseases,Fibromyalgia and focal vulvitis etc.
Aetiology:The IC as such is a complex condition with no direct etiological agent to attribute this condition to. Neurological/allergic/autoimmune/stress-psychological conditions have been supposed to be playing a role in these conditions. Presence of MAST cells in the bladder is supposed to be a pathognomonic marker of the disease. The association of mastocytosis, IC and inflammatory bowel disorders is intriguing. The bladder permeability defect due to lack of surface bladder glycosaminoglycans can lead to aggravation of the condition. The treatment now also is aimed at restoring this protective layer of the bladder.

Diagnosis:
The cystoscopic visualization of glomerulations is not a specific for diagnosis. Potassium chloride sensitivity test although not a specific again but can hint to success of pentosan polysulphate.
Management:
1. Behavioural modification: May help in patients having predominant frequency but less pain.

2. Diet: Certain foods can aggravate the condition like banana, cranberries, tea, coffee, alcoholic beverages, ketchups, Mayonnaise, carbonated drinks, junk foods, onion etc..


3.Medications: Antihistaminics to control mast cell proliferations,amitryptiline to fight with neurogenic inflammation,oral pentosan polysulphate to restore the protective layer of the bladder have been used in this condition with variable success rates.In india it is available as Comfora 100 mg three times a day for 3 months and then re-evaluate the patient.The side effects like nausea,diarrhea,rashes and reversible alopecia have been reported.Tachyphylaxis is also reported.
4.Bladder instillation therapies:DMSO – a wood pulp extract is the only agent FDA approved for the instillation.25% or 50% solutions have been used for the instillation.
With its ease of administration, lack of side effects, and dependable symptomatic results, DMSO has been a treatment of choice with many treating doctors. Some people add triamcinolone, 40,000 units of heparin, and sodium bicarbonate for better success.
5. Bladder distension:
Bladder distension stretches the bladder and gives a temporary relief for few months. It is done under general anesthesia. The bladder is distended for 2 minutes with 80 cm of H20 and then deflated again to see the glomerulations. Once it is done a therapeutic distension is done for 8 minutes followed by bladder biopsy for mast cells detection.
6. Radical surgical options are sometimes chosen like subtotal cystectomy with augmentation or ileal diversion with or without cystectomy. The results are somewhat positive. But as the underlying condition of neurogenic inflammation may not go -phantom bladder pain may persist.


LASER BLADDER NECK INCISION: SMALL FIBROTIC PROSTATE WITH BLADDER OUTLET OBSTRUCTION

A 60 year old gentleman came with complaints of weak stream,frequency,nocturia over a period of 1 year.He was tried on alpha blockers before but didnot respond.He was a known case of asthma in remission not on any brochodilators.His ultrasound has shown 20 cc prostate with 90 cc post-void residual urine and increased bladder wall thickness(6 mm).

His PSA was 1.77 ng/ml,urine culture was sterile and other hematological and biochemical parameters were normal.His uroflowmetry showed obstructive pattern.He was taken up for LASER BNI surgery.The bladder showed grade 2 trabeculations with high bladder neck.The prostate and the anterior urethra was grossly normal.The Bladder neck incision was carried out with continuous wave Thulium laser ( 2 micron) with 70 w power.The incision was carried out from the level of ureteric orifices till the level of verumontanum reaching to the depths of the capsule.At the end of the procedure the bladder neck region was widely open as seen with stopping the irrigation.The hemostasis was achieved and 18 Fr foleys catheter ( a 2 -way catheter) with no traction and irrigation.The plan is to remove catheter after 24 hours and give him a catheter free trial.

PCNL in complete staghorn calculus

A 45 year old lady came with left flank dull in nature since 6 months.She underwent a battery of tests including ultrasound KUB region and IVP which revealed a complete staghorn calculus on left side.Her other hematological and biochemical work up was essentially normal.She was taken up for PCNL.The patient and the attendants were explained about multiple settings and ESWL adjuvant therapy if need arises.
Today,PCNL was carried out with postero-inferior calyceal approach and around 70% bulk of the stone was cleared.The nephrostomy tube was left in the pelvis.The plan is to second session of PCNL after 48 hours with the same tract and using the flexible nephroscope for access to all calyces.

Tuesday, July 5, 2011

SEMEN BANKING: MUST BEFORE CHEMO/RADIOTHERPY IN YOUNG ADULTS


A 30 year old gentleman came to us with primary infertility.He had a very good educational background and belonged to banking sector.He was found to have severe oligospermia on evaluation.He was a known case of testicular carcinoma -Non seminomatous having undergone adjuvant chemotherapy.He was never counselled about sperm banking before the institution of chemotherapy.
One 1999 survey conducted by the Cleveland Clinic Foundation found that only about 50% of cancer patients receive adequate information about their post-treatment reproductive options, and that only about 25% of men eligible to bank sperm do. Given that the survival rate for testicular cancer is so high, quality of life issues such as family building are relevant to literally millions of cancer survivors like the one in our case.
The patient has just to visit the sperm bank and deposit the semen.The initial semen analyiss is done and then the semen is cropreserved.Even if the patient has undergone orchiectomny initially it is worth visiting the sperm bank and store whatever sperms he has now.With the advances in Assisted Reproductive Technologies and ICSI even a single sperm cell can be utilised for the successive IVF.
What is sperm bankingThe sperms are cryopreserved.With the induction of cooling the metabolic rate of the sperm is brought to a minimum level and they are halted in a state of suspended animation till they are thawed.The cooling and thawing can damage the sperms if done repeatedly but the sperms so obtained doesnot appear to altered genetic material.

FINASTERIDE GIVEN FOR HAIR REGROWTH MAY LEAD TO MALE INFERTILITY



Recently a 27 year old gentleman came to us with severe oligospermia.He was a case of hair transplant on finast low dose.There was no other cause discernible for oligospermia.He was asked to stop finast and at the same time advised to take anti-oxidnats to increase the sperm count.He was requested to come after a period of 3 months with fresh report of semen analysis.

Androgenetic alopecia (male pattern hair loss) is caused by androgen-dependent miniaturization of scalp hair follicles, with scalp dihydrotestosterone (DHT) implicated as a contributing cause. Finasteride, an inhibitor of type II 5alpha-reductase, decreases serum and scalp DHT by inhibiting conversion of testosterone to DHT.It is usually given in the low dose of 1 mg/day for accentuating the hair growth in the male pattern baldness.It has been argued that the finasteride doesnot affect spermatogenesis in normal health men in low dosage.But it might affect if the person who is taking the medications has already compromised spermatogenesis.
As most of the patients undegoing treatment for hair regrowth are in the younger age group.The treating surgeon/physician/dermatologist should take into his/her account his fertility status.

LASER EPILATION OF THE NEOURETHRAL HAIR

A 57 year old gentleman -case of urethroplasty with scrotal flap for anterior urethral stricture- had complaints of unabated dysuria and recurrent UTIs.There was no relief with the antibiotic therapy(both curative and suprressive).His urethroscopy had revealed adequate lumen(with diverticulae) with plenty of hair arising out of the scrotal flap area used for urethroplasty.He is presently planned for LASER(continuous 2 micron Thulium LASER) epilation.The hair might be acting as reservoir for the recurrent infections and also could result in dysuria.

Bladder mass in a young patient

A 27 year old patient came with complaints of lower urinary tract symptoms mainly irritative in nature.The patient was treated outside with multiple courses of antibiotic therapy without relief.The sonography done further showed the bladder mass.The other investigations- including the urine culture,urine for malignant cytology,blood biochemistry and haemtology were essentially normal.

We evaluated her further with triphasic CT scan which revealed cystic enhancing mass in the left superolateral wall of the urinary bladder with no iliac lymphadenopathy.The other intra-abdominal organs were normal.



She was taken up for cystoscopy and biopsy.The mass was extravesical.Adequate biopsy was taken with resectoscope.Hemostasis was achieved.The histopathological report is awaited.

Friday, July 1, 2011

Thulium laser prostatectomy: Tangerine technique-safe way of prostatectomy


In our hospital we follow -tangerine technique of laser prostatectomy. We use 2-μm -continuous wave thulium laser to dissect whole prostatic lobes off the surgical capsule, similar to peeling a tangerine. A 70-W, (thulium) laser was used in continuous-wave mode. We joined the incision by making a transverse cut from the level of the verumontanum to the bladder neck, making the resection sufficiently deep to reach the surgical capsule, and resected the prostate into small pieces, just like peeling a tangerine. The prostatic pieces were pushed into the bladder and later removed with the morcellation. We have rarely encountered bleeding. Saline was used for irrigation and hence no TUR syndrome occurs. Blood transfusion rate is less than 0.5%.We have even done patients on antiplatelet agents and patients with cardiac comorbdities.Recently we operated a 90-year old man with retention. The procedure was uneventful and the patient voided well after the surgery.
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Giant Pyonephrotic kidney: A lesson learnt

A 35 year old gentleman came to us with the left flank pain of 15 days duration.He was also complaining of generalised malaise.There was no complaint of fever or lower urinary tract complaints.He was complaining of dull ache in flank region previously also on and off.But the intensity as per the patient was not significant enough to seek consultation from doctor.He didnt have any comorbdities.There was no prior history of undergoing urological/ surgical interevention.Physical examination revealed a large mass in the left flank. Imaging showed a large hydronephrotic kidney with papery thin parenchyma.IVP showed a non excreting kidney even after 24 hours.Urine examination was unremarkable.







We explained the patient about non functioning status of the kidney and need for nephrectomy.Initial on table drainage then followed by laparoscopic nephrectomy vis-a-vis open nephrectomy options were considered.Finally we decided to go for open surgery.The kidney intra-operatively was grossly enlarged and full of thick creamy pus.A total of 3litres of pus was drained and then subcapsular nephrectomy was performed.


The pyonephrotic kidney removal is difficult surgery in view of loss of planes with the surrounding structures.Many times we are misled by the symptoms.We assumed that this would be a simple hydronephrotic kidney and thus surgery will be easier because of maintained planes.Absence of fever or absence of perinephric stranding on CT scan led us to assume so.Laparoscopy is pyonephrotic kidney would be a difficult task and waste of time; which can add to patients morbidity.Initial drainage (before surgery) would add a lot to our management strategy. If a clear urine drains out a laparoscopic surgery would be the treatment of choice.If pus is drained then open surgery can be assorted to.