Ramayya Pramila OPD Inauguration

Ramayya Pramila has been at the forefront of providing Affordable and Quality HealthCare in the field of Surgery and Urology for over four decades in Hyderabad.

To further his father’s Dr. G.P Ramayya vision and aspirations to give state of the art facilities and treatment Dr. Ramesh Ramayya envisioned a new OPD block which was inaugurated on the 19th of June 2013 at 11.30 am.

With urban architecture and planning the New OPD gives out contemporary look.The new OPD was opened by Smt. Pramila Devi Ramayya co-founder Ramayya Pramila Hospital . 

Smt. Sarala Kapoor inaugurated the Reception Area, followed by Shri. Seetharamaiah who inaugurated the Waiting Lounge area for the OPD patients.

Dr. P. Rama Rao inaugurated the Emergency Room and Dr.Seetha inaugurated the Clinics & Diagnostic Center.

To give a brief overview of the the process flow of the OPD, the Patient Enters the Hospital approaches the Hospital Reception counter, gets the Registration form fills it and submit it to Front Office Executive.

Front Office Executive Collects OP Fees (inclusive Registration fees for the New Patient), Registers the patient in the Excelicare, issues New OP book to the patient and gets consent signature on it.

Front Office Executive directs the patient to Waiting Lounge and informs the Clinic Assistant about the arrival of patient and the Consultant Preferred.

Clinic Assistant will accompany the patient from the Waiting Lounge to the Preferred Consultant Clinic.

After Consultation is over the OPD notes will be scanned, stamped and entered in Excelicare by Clinic Assistant. The OP Book will be handed over to Patient.

Planned OPD Timings: 2.00 P.M.to 9.00.P.M

CONSULTANTS TIMINGS:

Dr. Abdul Fatah - 2.00 P.M. to 5.00 P.M all week days except Sunday

Dr.Vamshi Krishna - 5.00 P.M. to 8.00 P.M. all week days except Sunday

Dr.Naveen Chandra Acharya - 5.30 P.M. to 8.30 P.M. all week days. Sunday 6.00 P.M. to 8.00 P.M.

Dr.Ramesh Ramayya - 12.00 P.M. to 2.00 P.M all week days except Sunday

Dr.Ratan Jha - 5.30 P.M. to 8.00 P.M.all week days except Saturday and Sunday.

Dr.Runa Kamat Acharya - 5.30P.M to 8.00 P.M. based on the appointments

Founder's Day

The Founders Day was celebrated on 26th May 2013 with great enthusiasm among the Ramayya Pramila family.

The Founders Day event was inaugurated with the lighting of Lamp by Chief Guest,Dr.Shiva prasad, Guest of Honor Dr. Naveen Chandra Acharya and the Consultant Urologists.

The Center Manager,Mr.Satish Pasagada, in his presentation spoke about the development of the Organization, the journey of the Hospital,the service, care, discipline and dedication of the founders to build the hospital as a pioneering centre for urology in Hyderabad.

The Chairman's Dr. Ramesh Ramayya message was delivered to the audience. 
Later the Chief Guest, presented awards for Best Long Standing Employee in the categories of Clinical and Nonclinical. 

Following which the Guest of Honor, Dr.Naveen Chandra Acharya presented awards for the Best New Employee in the categories of Clinical and Nonclinical. 

Lastly,the Vote of Thanks was given by Mr.Subramanyam, Asst Manager Non Clinical.

RAMAYYA PRAMILA HOSPITAL PERFORMS FIVE NEPHRECTOMIES IN A WEEK

We performed a total five nephrectomies this week.

1)Case of non- functioning kidney because of Pelvi-Ureteric Junction obstruction.A child of 9 years came with pain in left  flank  and on investigation was found to have NFK(DTPA renogram- void area).

He was taken up for left Laparoscopic nephrectomy.The approach was transperitoneal with three ports in place.The procedure was done uneventfully and the patient was discharged after 48 hours postoperatively.

2) Xanthogranulomatous kidney: A 80 year old lady came with recurrent fever and right flank pain.

On investigation was found to have large renal pelvic calculi with non functioning kidney.Because of her age and CT scan showing large pus pockets and severe perinephric stranding ; we safely resorted  to open nephrectomy.We found dense perinephric adhesions and could do subcapsular nephrectomy.The patient had ESBL MDR bacteria and hence was started preoperatively on colistin and sulbactam combination.The fever did not abate even after the surgery and the patient started getting diarrhea.Her counts were raised to 20,000/cmm and the procalcitonin levels were more than 100 units.We added Daptomycin antibiotic therapy.Subsequently the patient recovered.

3) Pyonephrotic kidney: A 53 year old lady came to us with fever and large tender right kidney( there was history of multiple urological interventions in the past like ESWL,PCNL).She was septicemic with polymorpho leucocytosis.

We did urgent right PERCUTANEOUS NEPHROSTOMY.It drained 500 ml pus instantly.The pus grew MDR klebsiella and hence was started on MEROPENAM 1 gm IV TID and was taken up for laparoscopic nephrectomy after 1 week of the PCN.The approach was transperitoneal with four ports.The nephrectomy was as anticipated difficult with perinephreic adhesions.The patinet recovered unevetfully after the surgery.

4)We did right nephrectomy(open) for a patient of ADPKD with End Stage Kidney Disease on Maintenance HD.A 50 year gentleman a known case of ADPKD came with abdominal distension, pain and  respiratory distress because of mas effect from the phenomenally large  kidneys.He was end stage renal disease on maintenance dialysis. 

He was referred to our centre for nephrectomy of a symptomatic kidney.The patient was considered for open nephrectomy as we thought laparoscopic nephrectomy would be difficult for want of space in the abdomen.The other option of renal angioembolisation was also not preferred for the fear of postinfarction sequel  and there was a consensus that the removal of renal mass would only be the best relief for distension and the respiratory distress because of the mass.

The both kidneys were 28 cm (left) and 22 cm( right ) respectively.He was symptomatic on the right side so we preferred for right nephrectomy.

The rooftop incision was given and the colon was reflected .The right kidney was huge and was crossing the midline over the great vessels.The lower part of the kidney was solid ( haemorrhagic cyst).The kidney was mobilised all around and the hilum was secured and renal mass was removed.

We went for marsupialisation also on left side for two prominent cysts at the same time( around 6 cm each two cysts).

5).A 30 year old young gentleman came with pain in left flank.On investigation; he was found to have left lower polar mass.On CECT ; there was heterogeneous enhancing cystic mass in the lower pole encroaching till the hilum.There was perinephric stranding.
We took the patient for left Radical nephrectomy (Laparoscopic nephrectomy).The approach was trans-peritoneal with three port.The colon was reflected and the kidney was mobilised outside the Gerotas Fascia.The hilum was secured and cut with Hem-o-Lock clips ( artery followed by renal vein).The specimen was retrieved after the camera port site was extended by 3 inches more.

        

ABIRATERONE ACETATE IN HORMONE RESISTANT CARCINOMA PROSTATE

A 52 year gentleman a case of prostatic metastases (HRPC) came from African continent for further treatment.He had already taken a course of docetaxel( 8 sessions of 80 mg/m2) and Extandi(Enzalutamide).

He had progressed after these medications.Presently he had multiple bone metastases(painful) , preserved performance , preserved renal and hepatic functions (raised alkaline phosphatase around 800 U/L.).His PSA levels were 234 ng/ml.

Because the bony pain was not getting relieved by routine NSAIDS, tramadol and fentanyl patches; we decided to go for Samarium Radioactive therapy.

Three radionuclides are currently approved for the treatment of bone pain: first-generation phosphorus-32 (32P), second-generation strontium-89 (89Sr), and third-generation samarium- 153 (153Sm). These radionuclides all localize to regions of enhanced bone turnover and deliver high local doses of radiation through the emission of beta particles. The mechanism of bone targeting varies for each of them. 32P is targeted to bone through inorganic phosphate pathways and, in a similar manner, 89Sr is taken up as a calcium analog. 153Sm, however, is the only agent in its class targeted to bone via chelation to the aminotetraphosphonate EDTMP (ethylenediaminetetra- methylenephosphonic acid). Side effects are limited to transient and relatively mild platelet and neutrophil suppression. Repeated doses can be used in patients whose marrow reserve is adequate at the time of administration. The short physical half-life of 153Sm (1.9 days) results in a more rapid delivery of radiation than either 32P (14.3 days) or 89Sr (50.5 days).

Metastatic bone disease contributes significantly to the morbidity and mortality associated with prostate cancer. Patients with bone metastasis complain of bone pain as well as of symptoms arising from bone marrow failure, nerve entrapment, and spinal cord compression. There is a direct relationship between the extent of osseous involvement and patient survival.He has lower hemoglobin 10.5 gm/dl and had girdle pain around the waist with paresthesia in right lower limb.

we started him on concurrent Gabapentin for neuralgic symptoms and also started him on Abiraterone acetate.

Abiraterone inhibits 17 α-hydroxylase/C17,20 lyase (CYP17A1), an enzyme which is expressed in testicular, adrenal, and prostatic tumor tissues. CYP17 catalyzes two sequential reactions: (a) the conversion of pregnenolone and progesterone to their 17-α-hydroxy derivatives by its 17 α-hydroxylase activity, and (b) the subsequent formation of dehydroepiandrosterone (DHEA) and androstenedione, respectively, by its C17,20 lyase activity. DHEA and androstenedione are androgens and precursors of testosterone. Inhibition of CYP17 activity by abiraterone thus decreases circulating levels of testosterone.

This drug has been now commonly used in patients with docetaxel resistant carcinoma prostate.In September 2010, an independent panel found that the interim results of the phase III clinical trial in previously treated docetaxel patients were so successful that it would have been unethical to keep half the trial participants on placebo, and all patients began receiving the drug. Overall survival was increased by 3.9 months according to this trial (14.8 months versus 10.9 months for placebo). It was approved by the FDA in April 2011.

The dosage of the medication is 1000 mg( 250 mg four tablets on empty stomach).The medicine is now available in India by Ranbaxy(ZELGOR).The medicine is used along with prednisolone 5 mg twice a day as the trials have proven the combination being more successful than the monodrug therapy.

The common side effects (>5 %)are joint swellings, muscle pain, hypokalemia,hot flushes,gastrointestinal side-effects etc.The patients with liver dysfunction ; we need to tailor the dosage to 250 mg once a day.

In our patients ; we had to stop ketoconazole that we had started as an interim drug as the Abiraterone interacts with the CYP3A4 drugs.

The patient is tolerating the medication well and is only complaining of fatigability.

So our patient is treated with combination of multiple drugs; Samarium 153 for painful bony metastases, Abiraterone for prevention of the progression of the malignant disease, Gabapantin for neuralgia and Zoledronic acid (bisphosphonates) to prevent Skeletal Related Events(SRE). 

JOHANSON URETHROPLASTY FOR HYPOSPADIAS

A 29 year old gentleman came for repair of the hypospadias.He had undergone three surgeries prior(chordee correction - first surgery,correction of hypospadias - second{ failed} so lay open surgery as the last one)  and had  good skin skin plate.
We took him up for Johanson urethroplasty.The skin was tubularized over a 14 Fr Foleys catheter and the neourethra was covered with the tunica vaginalis flap.

NEPHRECTOMY IN AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

A 50 year gentleman a known case of ADPKD came with abdominal distension, pain and  respiratory distress because of mas effect from the phenomenally large  kidneys.He was end stage renal disease on maintenance dialysis. 

He was referred to our centre for nephrectomy of a symptomatic kidney.The patient was considered for open nephrectomy as we thought laparoscopic nephrectomy would be difficult for want of space in the abdomen.The other option of renal angioembolisation was also not preferred for the fear of postinfarction sequel  and there was a consensus that the removal of renal mass would only be the best relief for distension and the respiratory distress because of the mass.

The both kidneys were 28 cm (left) and 22 cm( right ) respectively.He was symptomatic on the right side so we preferred for right nephrectomy.

The rooftop incision was given and the colon was reflected .The right kidney was huge and was crossing the midline over the great vessels.The lower part of the kidney was solid ( haemorrhagic cyst).The kidney was mobilised all around and the hilum was secured and renal mass was removed.

We went for marsupialisation also on left side for two prominent cysts at the same time( around 6 cm each two cysts).

The incision was closed with a drain in situ after achieving haemostasis. The patient is recovering uneventfully and has been put on haemodialytic therapy.

PCNL IN A STAGHORN CALCULUS

A 40 year old gentleman came with staghorn calculus in left kidney.He was taken up for PCNL after due investigation and prophylactic antibiotic therapy.

The staghorn was complete and we had to resort to 5 punctures.

We usually plan the punctures prior and do at the beginning only and place guidewires.We do CT Urography in all staghorn calculi.The Tracts were dilated with Atkins metallic dilators till 30 Fr was broken with pneumatic lithotripsy.The other tracts were subsequently dilated and complete clearance was achieved.We used flexible nephroscopy and Holmium LASER lithotripsy for calculus fragments in the inaccessible calyces.   

ESWL FOR LARGE PELVIC CALCULUS IN A CHILD

 The advent of extracorporeal shock wave lithotripsy (ESWL) as a non-invasive technique has revolutionalised the management of urinary tract calculi.  It is considered a safe and effective treatment for urinary lithiasis in adults.  However, the application of this modality of treatment in children followed rather slowly.   
ESWL over the time has been  found to be a safe and effective primary treatment modality for renal and ureteric stones in children. It had a high success rate and minimal short-term complications. Large staghorn calculi required multiple shock wave sessions and exposed the ‘young’ kidneys( still to be mature) is a concern. 
Even in big calculi it has been noticed that the  child's ureter is capable of transporting the fragments after lithotripsy. Interventional procedures should be a last resort. Expectant management is usually adequate even in patients who develop steinstrasse after ESWL. 
The other visceral organs like lungs should be protected by the polystyrene shields , the positioning in smaller children is challenging and needs expert and delicate  handling.The children are usually administered general anesthesia.
We have been doing routinely ESWL in smaller children with high successful outcome and fortunately did not need any auxiliary procedures.Febrile complications were minimal and treated conservatively.We routinely chose the stones less than 2 cm in paediatric age group.
The case shown above was 4 year old girl with 2 cm calculus in pelvis.The child was taken up for stenting and ESWL under general anesthesia The stone fragmented was carried out under USG guidance with shock wave intensity of 2 ( Dornier Lithotripsy).A total 2000 shocks were delivered with foam shields protecting the lungs of the child.The stone fragmentation was satisfactory .The child was given prophylactically antibiotics and the procedure was uneventful.

The child was discharged after 24 hours.                                               

FOUNDER DAY CELEBRATION OF RAMAYYA PRAMILA HOSPITAL ON 26 TH MAY 2013

The Founder day of Ramayya Pramila Hospital was celebrated on a grand note on 26th May 2013.The unique concept of super speciality hospital was first time introduced in India ( and probably in the world too) by our Founder Dr G.P.Ramayya.The hospital is rendering excellent dedicated services to the patients for continuous 42 years now.The visionary Founder aimed for services which will aim at complete clinical ,administrative and financial satisfaction.

The hospital has four full time urologists who give 24X7 services and is well equipped with state of the art equipments.

The function started with traditional lighting of the Jyothi 

and then the famous thoughts penned down by our Founder were read out ...

It is indeed a tragedy of circumstances my GOD, that my livelihood should depend upon the sickness of others. But, also, my good fortune that you have given this excellent opportunity to mitigate their suffering and thus atone whatever selfish interest I may have; You have cast upon my shoulders this great responsibility. Grant me the strength, my GOD, to enable me to fulfill this task in all my earnestness. 

Grant that I do not look upon my patients as a source of income, let nothing but desire to restore their health be my sole motivation and while so doing, let neither the wealth nor the poverty of the patient influence my decision.

This clinical and administrative staff gave their speeches followed by presentation of best employee awards.

AUDIENCE AT THE CONFERENCE HALL

MR DHARMENDER SUPERVISER GETTING BEST EMPLOYEE AWARD

CONSULTANTS LIGHTING THE JYOTHI AT THE INAUGURATION  

JAYAPRAKSH SENIOR OT NURSE  GETTING BEST EMPLOYEE  AWARD

RAMAYYA PRAMILA TEAM

MR VENKATESH OT ASSISTANT( 22 YEAR OLD ASSOCIATION WITH THE HOSPITAL) GETTING BEST EMPLOYEE AWARD 

DR NAVEENCHANDRA ACHARYA DELIVERS YOUNG SCIENTIST AWARD LECTURE AT 14 TH APSSM , KANAZAWA,JAPAN

Our chief urologist Dr Naveenchandra Acharya just  delivered the prestigious Young Scientist Award Lecture on the topic of " Endothelial Dysfunction and its correlation with the Erectile Dyfunction" at 14 th APSSM conference held at Kanazawa,Japan on 1st June 2013.

This paper underlines the importance of the endothelial dysfunction in erectile problems and the need to recognise this entity earlier before the onset of late complications of generalised endothelial dysfunction like CAD and stroke.

The endothelial dysfunction precedes many years before the onset of heart and brain catastrophe and hence its is essential to screen the people with erectile dysfunction.As penile vessels are only 1-2 mm in diameter while the left anterior descending coronary artery is 3-4 mm in diameter the early atherosclerotic and endothelial changes are likely to cause erectile dysfunction first then the myocardial Infarction.

We use Flow Mediated Dilatation Phenomenon for measuring the endothelial dysfunction ( it is done by inducing shear stress in brachial artery by occluding the sphygmomanometer cuff above systolic blood pressure and then relieving it.The reactive hyperemia and the reperfusion injury associated brachial arterial dilatation is measured by greyscale ECHO probe in antecubital fossa over the baseline diameter at "R" wave of ECG...corresponding to the end-diastolic phase).In patients with generalised endothelial dysfunction this response is blunted.

The other way of measuring the endothelial dysfunction is ENDOPAT.It measures the peripheral arterial tone by modified finger plethysmographic probes attached to the index finger of each hand.The procedure is the same like FMD but it is objective and easy to be done.It also eliminates the error by sympathetic overactivity.

We found there is significant decrease in FMD in patients with ED and its correlates with the severity of ED( as per IIEF-5 2 Questionnnaire).The patients were chosen with age less than 40 years and there was no cardiac problems and also no confounding factors like penile structural abnormalities, no medications,hormonal disturbances etc.

This is an important study as this can potentially screen people who will develop CAD in future and preventive steps can be taken in this regard.

This paper was highly regarded and appreciated at Kanazawa.