Dr.Ramayya's

Large Staghorn kidney stone in a patient with myelodysplastic syndrome removed by PCNL through a SINGLE TRACK

2012-01-27T01:35:00.000-08:00

A 60 year gentleman, suffering from myelodysplatic syndrome presented with left flank pain. On evaluation there was a complete staghorn calculus in the left kidney. He had a history of left open pyelolithotomy 20 years ago. His coagulation profile was normal. PCNL was done through superior calyceal puncture, and complete stone clearance was achieved. Postoperative recovery was uneventful.

Pre Operative KUB

Post Operative KUB

Partial staghorn kidney stone removed by PCNL through a single track

2012-01-27T01:18:00.000-08:00

A 50 year gentleman presented with left flank pain.On evaluation there was a partial staghorn calculus in the left kidney. Percutaneous nephrolithotomy (PCNL) was done through posterior inferior calyceal puncture. One middle calyceal stone fragment was removed by harpooning with the puncture needle. Complete clearance was achieved. Postoperative period was uneventful.

Plain KUB

IVP

Post Operative KUB

UNUSUAL CASE OF BLADDER CANCER WITH STAGHORN KIDNEY STONE

2012-01-20T00:39:00.000-08:00

A 65 year old female patient presented with burning micturation, pain in right flank, fever since 3 months followed by not passing urine(Anuria) since 1 week.

She was diagnosed to have Kidney failure with serum creatinine 3.5 dated 12/12/2011On 13/12/2011-Serum Creatinine was 4.9Ultrasound :reveals Right severe hydronephrosis with renal staghorn calculus 42mm,Left hydroureteronephrosis, changes of Cystitis.

CT scan of abdomen : shows Right renal staghorn calculus with satellite calculi and gross hydronephrosis with thinning of the cortex.

Left moderate hydroureteronephrosis – compensatory functioning. Grossly thickened urinary bladder wall.

Cystoscopy-Severe Trigonitis, bladder thick walled, illdefined mass at bladder outlet, ureteric orifices not identified.EUM-narrow dilated with Hegar dilators. Mucosal biopsy taken

As Ureteric orifices were not seen so fluroguided Bilateral PCN was done. Serum creatinine was repeated after Cystoscopy 2.3. Right PCNL was done with Single Track and stone was completely cleared, and then Serum creatinine was 1.0

In view of infiltrative bladder growth and bilateral hydroureteronephrosis, Radical cystectomy + Ileal conduit was done.

Final HPE Report - Infiltrative Squamous cell carcinoma stage pT4 N0 M0

Post Operative Recovery uneventful

Pre Op KUB

Post Op

Laparoscopic partial cystectomy for the urachal cyst

2011-07-18T07:11:00.000-07:00

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

2011-07-18T07:02:00.000-07:00

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

2011-07-18T06:40:00.000-07:00

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

2011-07-18T06:27:00.000-07:00

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.

Interstitial cystitis/Painful bladder syndrome: A review

2011-07-06T06:31:00.000-07:00

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

2011-07-06T00:59:00.001-07:00

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

2011-07-06T00:21:00.000-07:00

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.

SEMEN BANKING: MUST BEFORE CHEMO/RADIOTHERPY IN YOUNG ADULTS

2011-07-05T05:37:00.000-07:00

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

2011-07-05T05:06:00.000-07:00

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

2011-07-05T01:27:00.000-07:00

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

2011-07-05T01:08:00.000-07:00

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.

Thulium laser prostatectomy: Tangerine technique-safe way of prostatectomy

2011-07-01T05:23:00.000-07:00

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

2011-07-01T00:29:00.000-07:00

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.

Forgotten ureteric stent:Avoidable condition

2011-06-30T23:56:00.000-07:00

In urology stents have a special place.In almost all cases pertaining to endourology; stent placement is usually assorted to.The stent less surgery is gaining momentum but majority of the urologist including the ones in our centre are very comfortable with stented surgery.The stents have its own complications like stent related pain,dysuria,UTI etc in the immediate post-operative period.But if the stent is kept inadvertently for longer period then stent encrustation,stone formation,stent fragmentation can alos occur.Most of the cases the forgotten stent is due to poor compliance.But still the treating urologist needs to be proactive in pursuing such cases.Stent registry is a good concept as it is practically impossible to follow up each and every patient without systematic dedicated registry services.

Forgotten stents are dealt on the merit of each case.The intervention can be open surgery,URS,PCNL,Cystolithotripsy superadded with the ESWL.With the advent of LASER; almost all the cases can be dealt with endourology.

A 47 year old patient came to us with prior history of stone disease treated with ESWL and stenting 4 years back.She was suffering from recurrent UTIs.She was investigated and we saw a forgotten stent with stone formation at the both ends.She is planned for LASER cystolithotripsy and LASER URS and stent retrieval from below after cutting it at the level of the pelvi-ureteric junction.Then followed by PCNL for the partial staghorn calculus formed at the upper end of the calculus.

GENITO-URINARY TRACT TUBERCULOSIS

2011-06-29T07:03:00.000-07:00

A 38 year old lady presented to us with lower urinary tract symptoms and right flank pain for 15 days.She had history of undergoing left nephrectomy in 2002.The histopathological evaluation had shown granulomatous nephritis.After the surgery; she was advsied scrupulous follow-up but she could not regularly visit the surgeon.On presentation to our hospital; she had deranged creatinine(2.7 mg%) with sonographic evidence of right moderate hydroureteronephrosis.Non contrast CT scan evaluation confirmed the sonographic findings.She was taken up for retrograde pyelography and stenting.The findings on RGP were hydroureteronephrosis with a stricture at pelvi-ureteric junction.The bladder capacity was small around 90 ml.She was subjected to bladder biopsy.

GUTB: A REVIEW
Genitourinary tuberculosis is hematogeneous infection of the kidneys. The kidney being a primary organ the rest of the organs are affected by direct extension. The disease progression depends upon the host immune response.
The urologist many a times consider the GUTB as the diagnosis of exclusion. Any longstanding lower urinary tract symptoms with obvious cause detected makes the urologist suspicious about the disease.
Recurrent UTIs, frequency, dysuria, painless hematuria, painful ejaculation, anejaculation etc are the predominant symptoms.
Pathology: Tuberculosis results in development of Caseating granulomas - Langhans giant cells surrounded by lymphocytes and fibroblasts. The course of the infection depends on the virulence of the organism and the resistance of the host.
The healing process results in fibrous tissue and calcium salts being deposited, producing the classic calcified lesion. The disease because of fibrotic/calcific nature results in development of strictures,deformed calyces,small capacity bladder(so called thimble bladder).The irony of the treatment is that the starting of the antiKochs medications results in further fibrosis.This can lead to further narrowing of the strictures and / or further decrease in bladder capacity.
We therefore usually add steroids in initial management to prevent further compromise of the renal functions.
In the present case the disease had already taken a toll of left kidney.(hematogeneous route).The rest of the disease was probably because of direct extension( small bladder capacity and multiple ureteric strictures).
The treatment in our case was –stenting to safeguard the kidney function by stenting,bladder biopsy for getting final histopathological proof.The next strategy would be starting her on AKT and steroids and keep stent for 3-6 months period.Any recurrent stricture/persistence of thimbe bladder would need specific surgery.

Recurrent ovarian cyst causing left ureteric obstruction

2011-06-24T22:32:00.001-07:00

A 40 year old lady presented with history of left flank pain of 15 days duration.There was recent exaggeration of the pain intensity.There was no history of fever,dysuria and lower urinary tract symptoms.She gave history of having been operated for ovarian cyst 3 months back.The histopathological report of the cyst was benign.

The biochemical and hematological parameters were normal.CA-125 antigen assay was also normal.The urine analysis didnot reveal any abnormality.The USG abdomen showed left hydroureteronephrosis with cyst in pelvis.The ureter could be traced only to the cyst region.She was subjected to Contrast Enhance CT scan which showed cyst compressing the ureter causing hydroureteronephrosis.

She underwent RGP and DJ stenting followed by aspiration of the cyst under USG guidance.The cytology of the aspirated cyst was essentially normal.Two weeks post-operatively the patient is doing well.We have planned a repeat CT scan after a period of 6 weeks and decide further management.Any recurrence of the cyst would then need laparotomy with cyst removal.

Complication after ileal conduit done for urinary diversion post radical cystectomy

2011-06-10T04:49:00.000-07:00

A 65-year-old lady underwent radical cystectomy for TCC bladder 1 year back.The surgery was uneventful.The mode of diversion was ileal conduit.The post-operative histopathology read as TCC T2N0.In the post-operative follow up she had recurrent UTIs and at the end of 1 year post-op her creatinine was around 2.3 mg%.

The imaging showed no local or systemic recurrence and the upper tracts showed changes of hydroureteronephrosis.The EC scan done to reveal the pattern of drainage didnot reveal any prolonged stagnation above uretero-ileal junction.During one such episode of UTI;we decided to put the catheter in the conduit for better drainage and then we realised that there was difficulty in catheterisation because of kinking at parietes.

We perfomed dynamic contrast study under fluoroscopic guidance; it showed adequate draiange.

With every episode of UTI she usually used to get elevated RFTs and the same used to settle down after the institution of the antibiotics and the conduit catheterisation.

We revised the stoma and the conduit was released from the parietes thinking that that would relieve the blockage but it didnot.After the stomal revision also she landed up again in UTI.

We went ahead and did percutaneous nephrostomy for her on both sides for the raised creatinine and the urosepsis.After the PCN her came down and got stabilised at 1.8 mg% and also she was free from UTI for 2 months period.The patient is still on bilateral indwelling PCNs and we are planning to go ahead with nephrostogram.If the nephrostomgram reveals any stagnation then the revision of the uretro-ileal junction will be needed.

The case was brought up here to discuss the long term complication of ileal conduit.The deterioration of kidney function,recurrent urosepsis,stomal complications are possible complications of ileal conduit diversion.

RIRS: Retrograde Intra-renal Surgery ensures complete clearance of renal stone

2011-06-09T23:41:00.000-07:00

In this case stenting and ESWL had left one residual fragment in the renal pelvis.

OUR RIRS URETEROSCOPE
In our hospitals;we routinely prestent the patient during ESWL. The reasons being two; one that stenting facilitates the passage of calculus fragments and at the same time safeguards kidney from any obstructive complications. Secondly in the event if the ESWL fails then RIRS during the stent removal can ensure complete clearance.RIRS in presented patient is comparatively easier task as the ureter is dilated and placement of ureteric access sheath becomes easier task.
Review of literature:
In RIRS; a fibre-optic tube is inserted through the urethral meatus into the kidney after passing it through bladder and the ureter. The stone is visualized and is thereafter evaporated by a laser probe. We have a 20 W Holmium LASER(Sphinx). The procedure is usually done under general or spinal anesthesia. Retrograde Intrarenal Surgery (RIRS) allows the surgeon to do surgery inside the kidney without making an incision/ and hole on the body.
The indications for RIRS include:
· Failed previous treatment attempts of ESWL
· Strictures
· Tumors
· Stones in children
· Patients with bleeding disorders
· Patients with gross obesity/KYPHOSCOLIOSIS etc

We combine the two modalities of ESWL and RIRS routinely in all patients and give 100% success rate after the procedure for all patients. The combination of these modalities ensure elimination of the need for more invasive procedures like PCNL.This is a special boon for patients having physical deformities like obesity or kyphosis.

palliative radical nephrectomy:Metastatic Renal cell Carcinoma

2011-06-09T22:55:00.000-07:00

A 75-year-old gentleman came to us after he was diagnosed to be having left renal mass.He initially had back pain for which he consulted spine surgeon.After initial conservative therapy failed;he was subjected to MRI spine.MRI revealed metastatic foci in dorsolumbar vertebrae.

His staging work up revealed enhancing midpolar mass in left kidney.The mass appeared to be confined to the kidney only although there was ipsilateral psoas thickening.It also revealed basal metastatic lung lesions.We came to conclusion of metastatic renal cell carcinoma.

As the patient had a good performance index and preserved biochemical and hematological parameters he was advised palliative nephrectomy.

The open radical nephrectomy was performed ; the post-operative course was uneventful.The final Histopathology read as Renal cell Carcinoma -Furhmann Grade 3 with T3 stage.

He is planned for Sunitinib therapy.(Sutent 50 mg cap/day ) along with possible radiation to the spine if needed.

REVIEW OF LITERATURE:

Renal cell carcimoma (RCC) is the third most common genitourinary cancer after prostate and bladder. Majority (80% to 85%) of kidney tumors are malignant. It is the most lethal malignancy of all urological cancers.Unique characteristics of RCC lack of early warning signs,§ diverse clinical§ manifestations, resistance to radiation and chemotherapy, and immunogenic nature and spontaneous regressions.

Pretreatment features associated with shorter survival

There are various studies identifying the pretreatment factors associated with poor survival. These are – Low Karnofsky performance status (< 80%)– High lactate dehydrogenase level (> 1.5 x normal)– Low hemoglobin level– High serum calcium– Absence of nephrectomy• Nephrectomy and resection of metastases has been reported to prolong the survival. Effect is enhanced with long disease-free interval between initial nephrectomy and development of metastases.

Survival also depends on the site of metastasis. Patients with lung metastasis only have better survival than those with other site metastasis. (Flanigan RC, et al. N Engl J Med. 2001; 345: 1655-1659.)

Available treatment modalitiesOptions for chemotherapy and endocrine-based approaches are limited, and no hormonal or chemotherapeutic regimen is accepted as a standard of care. Therefore, various biologic therapies have been evaluated. New agents, such as sorafenib and sunitinib, having anti-angiogenic effects through targeting multiple receptor kinases, and have been investigated in patients failing immunotherapy.

Role of Surgery Palliative nephrectomy should be considered in patients with metastatic disease for alleviation of symptoms such as pain, hemorrhage, malaise. Several randomized studies are now showing improved overall survival in patients presenting with metastatic kidney cancer who have nephrectomy followed by either interferon or IL-2. If the patient has good physiological status, then nephrectomy should be performed prior to immunotherapy. There are anecdotal reports documenting regression of metastatic renal cell carcinoma after removal of the primary tumor but adjuvant nephrectomy is not recommended for inducing spontaneous regression; rather, it is performed to decrease symptoms or to decrease tumor burden for subsequent therapy in carefully controlled environments. About 25-30% of patients have metastatic disease at diagnosis, and fewer than 5% have solitary metastasis. Surgical resection is recommended in selected patients with metastatic renal carcinoma. This procedure may not be curative in all patients but may produce some long-term survivors. The possibility of disease-free survival increases after resection of primary tumor and isolated metastasis excision.

RADIATION THERAPY:Radiation therapy may be considered as the primary therapy for palliation in patients whose clinical condition precludes surgery, either because of extensive disease or poor overall condition. A dose of 4500 centigray (cGy) is delivered, with consideration of a boost up to 5500 cGy. Preoperative radiation therapy has not been found to yield any survival advantage. Controversies exist concerning postoperative radiation therapy, but it may be considered in patients with peri-nephric fat extension, adrenal invasion, or involved margins. A dose of 4500 cGy is delivered, with consideration of a boost. Palliative radiation therapy often is used for local or symptomatic metastatic disease, such as painful osseous lesions or brain metastasis, to halt potential neurological progression. Surgery also should be considered for solitary brain or spine lesions, followed by postoperative radiotherapy. Stereotactic radiosurgery is more effective than surgical extirpation for local control and can be performed on multiple lesions.

Multi-kinase inhibitors:

Sunitinib (Sutent) Sunitinib is another multi-kinase inhibitor approved by the FDA in January 2006 for the treatment of metastatic kidney cancer that has progressed after a trial of immunotherapy. The approval was based on the high response rate (40% partial responses) and a median time to progression of 8.7 months and an overall survival of 16.4 months. The receptor .b and atyrosine kinases inhibited by sunitinib include VEGFR 1-3 and PDGFR Major toxicities (grade II or higher) include fatigue (38%), diarrhea (24%), nausea (19%), dyspepsia (16%), stomatitis (19%), and decline in cardiac ejection fraction (11%). Dermatitis occurred in 8%, and hypertension occurred in 5% of patients. A recent phase 3 study evaluating sunitinib in the first-line setting, , in patients with metastatic RCC demonstrated significantacompared against IFN- improvement in PFS and response rates compared against the control arm. These results are considered to be preliminary, and longer-term follow-up is necessary for conclusive results.Other multi-kinase inhibitors undergoing investigation for RCC Lapatinib is an EGFR and ErbB-2 dual tyrosine kinase inhibitor, which appears to have efficacy in the treatment of tumors, including RCC, which overexpress EGFR. This was recently reported in a phase 3 study in advanced RCC evaluating lapatinib against hormonal therapy in patients who had failed prior therapy.RAD001 (Everolimus) is a serine-threonine kinase inhibitor of mTOR, an important regulatory protein in cell signaling. A recent phase 2 trial in patients with metastatic RCC demonstrated promising preliminary clinical results

MATHIEU REPAIR FOR HYPOSPADIAS CRIPPLE

2011-06-02T07:33:00.000-07:00

LOUPE ASSISTED HYPOSPADIAS REPAIR

We did Mathieu repair for hypospadias cripple who had undergone four repairs for proximal hypospadias.As the local flaps on the dorsum(TPIF) and lateral based flap were unavailable the permeatal flap was raised and the repair was done satisfactorily.

Gross prostatomegaly with seminal vesicle hematoma presenting as acute retention of urine

2011-06-02T06:27:00.000-07:00

MORCELLATED PROSTATIC CHIPS

MRI SHOWING PROSTATOMEGALY WITH GROSS SEMINAL VESICLE DILATATION WITH MASS WITHIN

A 65 year old gentleman came with acute retention of urine.He was catheterised with 18 Fr Foleys catheter; around 1.2 litres of urine drained out.His imaging showed gross prostatomegaly with seminal vesicle dilatation and mass in the seminal vesicle.He further underwent MRI pelvis which demonstrated prostatomegaly with seminal vesicular cyst and hematoma/mass inside.His PSA value was normal and his previous TURPs(he underwent two TURPswithin a span of 2 years for acute retention of urine).The Histopathological analysis showed benign prostatomegaly only.He was taken up for laser prostatectomy and was planned for review imaging after 3 weks for seminal vesicular hematoma/mass.The catheter was removed on second day post-operatively and he passed urine in good stream with low residual urine volume.His histopathological analysis was again benign.In the post-operative period he presented with seconary bleeding on 7 Th day; so was taken up for cystoscopy and clot evacuation.There was organised clot in the prostatic fossa measuring around 6X6 cm.The mass had to be morcellated with the morcellator.After the procedure he was comfortable with clear urine.He was given catheter free trial two days later and passed urine freely.Review Imaging showed no seminal vesicular mass/dilatation.The prostatic mass was probably decompressed seminal vesicular hematoma which probably would have resulted in resolution of seminal vesicular dilatation.

LAPAROSCOPIC RADICAL NEPHRECTOMY FOR EXOPHYTIC MIDPOLAR RENAL MASSA

2011-06-02T05:44:00.000-07:00

A 70-year old gentleman came with incidentally detected right renal mass( on USG scan done for urinary retention).He was investigated with staging work up including triphasic CT Scan which revealed enhancing mass around 5 cm in midpolar region with both exophytic and endophytic component.

After explaining to the patient the options of both laparoscopic partial nephrectomy and radical nephrectomy he opted for laparoscopic radical nephrectomy.

Laparoscopic surgery was done with 5 port approach and the specimen was removed by a small right iliac fossa incision.

Seminal Vesiculoscopy:recent case in prostatic utricular cyst

2011-05-31T06:45:00.000-07:00

MRI SHOWING SEMINAL VESICULAR DILATATION

We operated a total 8 cases of seminal vesicle obstcruction over last year.

All had low volume ejaculate,azoospermia or severe oligospermia or hematospermia.Out of them;two cases of hematospermia totally resolved after the surgery.

Out of six cases of azoospermia(out of six); four improved- one couple even concieved.Two patients didnot improve.

This shows a great future for seminal vesiculoscopy in obstructive azoopsermia and also hematospermia.It helps in hematospermia.In one case it abated as we did removal of the seminal vesicle calculus in other case there was only congestive hematospermia.It probably helps in idiopathic hematospermia by decreasing the intraseminal vesicular pressures.

Ureterosigmoidostomy Follow up

2011-05-31T06:33:00.000-07:00

We had operated 45 year old lady - radical cystectomy and ureterosigmoidostomy for TCC bladder.She underwent the surgery uneventfully.

Post-operatively on 1 year follow up she underwent CECT urogram.Here is the scan photograph showing the ureteral anatomy.

Her hematological/biochemical and VBG analysis was essentially normal.She was passing urine every 1 hourly as per our instrcutions and was leading a very good quality of life.

The ureterosigmoidostomy had fallen out of favour recently due to advent of newer continent diversions like orthotopic diversions.But in select cases ureterosigmoidostomy can offer equal quality of life like orthotopic diversion.

transitional cell carcinoma with staghorn calculus

2011-05-31T06:05:00.000-07:00

We operated a case of renal tumor invading the descending colon .He underwent left radical nephrectomy with En Bloc Resection of the intestinal segment.

The patient was having staghorn calculus and nonfunctioning kidney.He was asymptomatic.

He underwent periodic imaging and blood biochemistry studies.This time he presented with signs of constitutional symptoms and dull continuous pain in the left flank.

His ultrasound showed mass in the kidney.He was further evaluated with Triphasic CT scan which revealed left renal mass with obscured planes with the descending colon and staghorn calculus.

He was taken up for surgery in view of his metastatic work up was essentially normal.

In 2 months postoperative period he is doing well and planned for palliative chemo/radiotherapy.

LASER prostatectomy in cardiac patients

2010-12-19T22:54:00.000-08:00

A 75 year old gentleman came with the history of lower urinary tract symptoms not responding to medical line of the therapy.The investigations showed the prostate was of 60 gm size and residual urine of 200 ml.

The patient was a case of cardiac illness and had pacemaker being inserted in 2009.He was on acitrom and clopilet for anticoagulation.

The clopilet was stopped 5 days before the surgery and the acitrom 3 days before the surgery and was started on clexane injection subcutaneously 60 mg once a day.The cefazolin was used pre-operatively as the surgical prophylactic medication.

The median lobe (prominently enlarged) was tackled with enucleation technique and lasovaporisation was done for rest the prostate.The procedure was uneventful with no bleeding.

Post-operatively there was no hematuria and 18 Fr double lumen was used without the need for irrigation.

This case is brought forward to show how safely LASER prostatecomy can be done in such cases.The routine TURP method in cardiac patient is frought with the danger of fluid overload,TUR syndrome and risk of bleeding.The present case was done with antiplatelt agent aspirin continuance.

LASER PROSTATECTOMY IN CHRONIC RENAL FAILURE PATIENT

2010-12-19T22:44:00.000-08:00

A 72- year- old gentleman came with retention of urine and altered renal parameters (Blood Urea 100 mg% and serum creatinine 7.6 mg%).The bladder was distended above the umbilicus and ultrasound showed the upper tracts showing bilateral backpressure changes ( cortical thickness on both sides was papery thin).The catheter was intoduced and the bladder was decompressed slowly and he developed post obstructive diuresis which was managed with proper fluid institution.

His creatinine dropped to 5 mg%.His prostate was 80 gm in size and serum PSA was within normal limits.The patient was a case of hypertrophic cardiomyopathy and has ejection fraction of 50%.

He was taken up for Laser prostatectomy and trilobar enucleation and morcellation was done uneventfully.Post-operatively the patient did well.

This case shows the safety of LASER prostatectomy in chronic renal failure patients.The advantage of LASER in such cases would be lesser bleeding, less chance of dyselectrolytemia( NS irrigation is used in contrast to Glycine in TURP)

Role of Interferon in mumps orchitis

2010-12-19T22:30:00.000-08:00

In andrological practice it is common practice to see mumps orchitis or infertility due to mumps orchitis.
In men orchitis represents the most common complication of mumps infection and occurs in 5 to 37% of this population. Bilateral manifestation is observed in 16 to 65% of the patients. The most important danger is the risk of testicular atrophy which results in sterility.
There are conflicting reports of role of systematic interefron-alpha-2 B in mumps orchitis.Some studies supporting its usage and some disputing its utility.
The usual dosage is 3 Millions units administered daily parenterally intravenous form for 7 days. Keeping in view with the low complication rate with systemic interferon therapy (flu like symptoms which can be tackled by paracetamol administration) the andrology department here uses this therapy and strongly advocates it in case of bilateral affection of the testes.

MICRODISSECTION TESE : HOPE FOR NON OBSTRUCTIVE AZOOSPERMIC PATIENTS

2010-12-19T22:21:00.000-08:00

A 35 year old gentleman came with history of azoopsermia/primary infertility.The work up showed he suffered from Sertoli cell only syndrome with FSH within normal limits.

He had history of mumps orchitis in childhood.

He underwent Microdissection TESE procedure in Dr Ramayyas Hospital in lieu with Oasis Centre for Fertility.The procedure was done in spinal anaesthesia with addition cord block with bupivacaine.The total time duration was 45 minutes and sperms could be retrieved although the motility of the retrieved sperm was feeble.The magnification which was used was 20 X and 5/0 DOUBLE ARMED PROLENE was used for closure of the tunica afterwards.

Radical Nephrectomy

2010-12-04T00:31:00.000-08:00

A 50 year old gentleman came with incidentally detected mass in right kidney measuring 8X6 cm in dimensions.He was a diabetic and hypertensive and COPD patient also.Because poor pulmonary function he was taken up for open radical nephrectomy.

The staging work up was essentially normal.

HIFU PATIENT INFORMATION

2010-11-21T22:42:00.000-08:00

Laser Prostate

2010-11-21T22:29:00.000-08:00

Penile Implant

2010-11-21T22:19:00.000-08:00

Laser Lithotripsy

2010-11-21T22:12:00.000-08:00

2010-11-21T21:59:00.000-08:00

Fast and convinient consultation system in Dr Ramayyas Hospital:

2010-11-06T04:34:00.000-07:00

We have started a disciplined approach in reception centre at Dr Ramayyas hospital wherein the patient would be seen within 10 minutes of his/her arrival in the hospital.The tests also will be carried out as soon as possible so a pausible cause of the disease and the medications will be started without delay.Our centre has three fulltime urologist and one Urology Associate available for the round the clock.These doctors are specialised in different areas so the patients as per the complaints and the disease will be seen by the superspecialist immediately.
The emergency patient also would be immediately seen without any delay.The delay in consulation is most annoying for the patient and the dillydallying in investigations and the reports also adds to their woes.
We have equipped ourselves with all the posible surgical investigational armamentarium-blood tests,USG(transvaginal,trans-rectal,Follicular Monitoring,penile doppler test),Radiology,uroflowmetry.Recently we have added Urodynamic machine with the state of the art urodynamic chair also to our armamentarium.We carry out semen analysis,vibrator therapy,intracavernosal injection tests,cavernosographies,Vacuum Erection Device test,Nocturnal Penile Tumuscence Test here.We have also installed state of the art surgical microscope to complete the andrology Lab.These equipments will prevent to certain extent patients being referred again and again to different centres.
Dr Ramesh Ramayya-CEO and the Chairperson of the Institute will be looking into prostatic diseases and endourology.Dr Nath-Clinical Director will look into urological reconstructive field apart from endo-urology.Dr Naveen Acharya-Consultant Urologist will see andrology-impotence and infertility cases with assistance from Dr Mahesh Sable-Medical Suptd. and seminologist to complete any seminological requirements.Dr Santosh - Consultant Urologist will look after areas of laparoscopic Urology and Female Urological aspects.

Alternative to Cranberry Juice in Recurrent UTI: D-Mannose and Proanthocyanidin scahet

2010-11-05T22:16:00.000-07:00

Millions of women world wide suffer from recurrent urinary tract infections.The symptoms are usually burning urination,freqency of the urination and pain in genital region or lower back region.The physician usually sends urine for culture examination and starts antibiotics either for 5-7 days duration or gives low dose antibiotics for long time for suppression of the annoying bacterial flora.The recurrent infections if due to some causative factor like diabetes mellitus(altered immunity),stones,prolapse,dry vagina(due to post menopusal changes),pregnancy needs to be looke into.
The suppressive antibiotic administartion usually causes cure in 70% of the cases but as soon as the antibiotic is stopped some 30% of the women suffer from the recurrent UTI.
Some strategies like cranberry juice or lignonberry juice is being started for most of the patients but the effect of such preventive measures is not clear and diabetc patients are not suitable for these medications as the quantity to be taken could be 250 ml to 500 ml daily.
To prevent adherence of the bacteria to the urogenital mucosa D-mannose and proanthocyanidin can be taken regularly.Sachets available in the market like Ugiclean sachet can be dissolved in glassful of water and can be consumed 4-6 times a day.It is safer in diabetic patients also.
D-Mannose is a natrurally occuring simple sugar which without alteration is filtred by the kidneys and reach the bladder.On reaching the bladder it allows the fimbria of E-Coli to preferrentially attach to them rather than the bladder mucosa.This forms a slipper complex ; and can be voided easily.The proanthocyanidins helps to buid immunity as it is 50 times more powerful than Vit E and 20 times more potent.
In a study conducted by Dr Michael Blue,Oklahoma 66 % of the women with recuurent UTI had culture negativity.In a related study 80% of the painful bladder syndrome patients had relief.

Naftoopidil in Benign Prostatic Hyperplasia

2010-11-05T21:52:00.000-07:00

Naftopidil is one new moleculethat has evoked renewed interest in pharmacotherapy for benign prostatic hyperplasia.It is a alpha 1 d receptor antagonist and inhibits significantly cell proliferation dose dependently in all cell lines that expresses alpha (1 d)-AR mRNA .It is said to be effective in sexually active men and those with irritative voiding symptoms..
It has been seen to reduce the nocturnal urine volume and hence cause less disturbance in sleep pattern.

Penis Fracture:An andrological Emeregncy

2010-11-03T23:24:00.000-07:00

A 25 year old gentleman married recently came to us with penile swelling after an episode of violent sexual activity.He presented with eggplant deformity of the penis with a large hematoma.

As a routine we performed retrograde urethrogram to see any urethral trauma.The urethral integrity was intact.He was immediately taken up for exploration;he underwent degloving incision of the penis and he underwent repair of the tunica with nonabsorbale sutures after evacuation of the hematoma.

He was discharged after 1 week and he regained his potency (as per the patient told on 8 week follow-up).

A penile fracture is an injury caused by the rupture of the tunica albuginea, which envelops the corpus cavernosum penis. It is most often caused by a blunt trauma to an erect penis.
Presentation
A popping or cracking sound, significant pain, immediate flaccidity, and skin hematoma of various sizes are commonly associated with the event. These symptoms are similar to a common bruising or contusion of the penis. If Bucks fascia is intact then ecchmosis is confined to penis and the penis may appear like eggplant and if the Bucks fascia is disrupted then “butterfly” hematoma may occur over the region of the perineum. Causes
In the western world the most common cause, accounting for about 30%-50% of cases, is intercourse. Of those, woman-on-top position resulting in impact against the male pelvis or perineum and bending laterally are most common.
The practice of taqaandan also puts men at risk of penile fracture. Taqaandan, which comes from a Kurdish word meaning "to click," involves bending the top part of the erect penis while holding the lower part of the shaft in place, until a click is heard and felt. Taqaandan is said to be painless and has been compared to cracking one's knuckles, but the practice of taqaandan has led to an increase in the prevalence of penile fractures in western Iran. Taqaandan is usually performed to achieve detumescence.

Diagnosis:
Penile fracture can be diagnosed by history or physical signs (a careful examination may reveal “Rolling sign”-palpation of blood clot over a break on tunica albugenia).In equivocal cases cavernosography or MRI may have to be performed. If urethral bleeding is also a presentation then retrograde urethrogram should be done to diagnose the urethral trauma.

Treatment and prognosis
Penile fracture is a medical emergency, and emergency surgical repair is the usual treatment. Delay in seeking treatment increases the complication rate. Non-surgical approaches result in 10%-50% complication rates including erectile dysfunction, permanent penile curvature, damage to the urethra and pain during sexual intercourse.
A circumferential degloving incision is given 1 cm proximal to the coronal sulcus then the trauma site is identified and the hematoma is evacuated. The defect in the tunica albugenia is repaired with inverting non-absorbale sutures.

KORO:PENILE RETRACTION SYNDROME

2010-11-03T05:18:00.000-07:00

A 35 year old patient came with the history of having gone through symptoms of penile retraction.He went through the turmoil for almost 4 hours.He says that he literally had to pull the penile shaft to prevent it from retracting into the body.
He had a particular misconception that if the penis would have totally involuted into the body then he would have died.He said that he heard a few people dying because of this condition.

Genital examination revealed no evidence of penile retraction.Although he was complaining about left testicular tenderness ;it appeared to be due to trauma sustained during the act of mechanical "pulling out".

First we thought the patient to be malingering but there two people with him who happened to be our patients in the past and vouched to have witnessed this condition.
We reassured the patient that such condition doenot exist and he is essentially normal.He was eduacted about his genital anatomy and explained that the penis cannot shrink inside the abdomen.
Later we did a dilgent search on the net.This condition appeared be akin to KORO (this word comes from the Malay-Indonesian word for tortoise) seemed to have been prevalent in China/South East Asia..
Most of the victims complain about episodes of acute attack of genital retraction or genital shrinkage, sometimes both. Each episode usually lasted several hours, though the duration can be as long as two days. There are cases in which koro symptoms persist for years with either chronic and continuous or recurrent history. On top of retraction, other symptoms include a perception of alteration of penis shape, loss of penile muscular tone.
Ideational components of koro include fear of impending death, penile dissolution and loss of sexual power. A man may perform manual or mechanical penile traction, or "anchoring" by a loop of string or some clamping device.
The treatment should be psychotherapy.

Penile Implant : A boon for erectile dysfunction

2010-11-03T05:11:00.000-07:00

We recently operated a 56 -year old patient with erectile dysfunction.He was a known case of Coronary Artery Disease with hyperlipidemia and was on anti-platelet agents.He was a non-responder to PDE-5 inhibitors and Vacuum Erection Device so was taken up for Penile Implant.A three piece penile implant of Mentor Coloplast was implanted with a penoscrotal incision and the reservoir was implanted in retropubic space.
The whole surgery took 1 1/2 hours with minimal blood loss.The ecosprin medication was stopped 1 week prior to surgery.
The patient was started on prophylactic antibiotcs and as a routine scrubbing of the genital area with Betadine scrub was started 5 days prior to the surgery.
The post-operative period was uneventful and the patient was discharged 2 nd post-operative day.

Urodynamic Facility at Dr Ramayyas Hospital

2010-11-03T05:03:00.000-07:00

We launched Urodynamic facilities and have started doing Urodynamic studies regularly on patients of voiding dysfunction.

We have installed Urocomp 2000 EU machine manufactured by status medical equipments with a special chair especially for female patinets.

Pharmacotherapy in Male Reproductive system disorders

2010-08-26T20:30:00.000-07:00

MEDICAL MANAGEMENT OVERVIEW IN ANDROLOGY:

ERECTILE DYSFUNCTION:

Pharmacotherapy of ED could intervene in the CNS: ALPHA 2 ADRENERGIC BLO0CKERS (YOHIMBINE,PHENTOLAMINE)and dopaminergic antagonist (APOMORPHINE ) or peripherally agents that enhance , elevate or directly stimulates the synthesis of secondary messenger molecules such as c AMP or c GMP and direct activators of adenylate cyclase for ex: Phosphodiesterase inhibitors :non selective –papaverine, Type 5 –sildenafil citrate,vardenafil,Tadalafil,Type 3 Milirinine and Type 4 roliparm
Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved Viagra, the first pill to treat ED. Since that time, vardenafil hydrochloride (Levitra) and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness. Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for tadalafil(Megalis,Forzest) is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug.
None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also patients have severe cardiac diseases like recent Myocardial Infarction, reduced stress tolerance should avoid PDE-5 inhibitors.

sildenafil
tadalafil
verdenafil
Maximum plasma concentration
30-120 (median 60)
30-360 (median 120)
30-120 (median 60)
Half life hours
4
17.5
4-5
Duration of action
up to 4-12
up to 36
Up to 4-12
Food restriction
may take longer to work with meals
can be taken with or with out food
can be taken with or without fatty foods
INTRA CAVERNOSAL INJECTION OF VASO ACTIVE DRUGS (ICIVAD)
Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride(15- 60 mg), phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including pain (36%) persistent erection (4%) and scarring. It gives a success rate of 70-90 % but these injections have a drop-out rate of 25-60% because of mainly pain or sometimes development of corporal fibrosis.
Methodology of giving papavarine/bimix:
Start with 29-30 G Insulin syringe for the injection therapy.

Papavarine:It can be started with 15 and given till 60 mg. Inject in any corpus.
Bimix: Add chlorpromazine ( 4 ml papavarine to 0.1 ml chlorpromazine combination) start with 0.1 to 0.2 ml and then gradually increased .Again the injection can be given in any one of the corpus
Drug therapy for Peyronie’s disease:
Medical Treatments
Various medications like Vit E 400 mgs three times a day for 3 months, Cochicine 0.5 mg 2 bd for 3 months or Tamoxifen 20 mg BD for 3 months.The placebo controlled trioals have not shown efficacy of the medications but colchicines there are no placebo studies. It seems to be effective.

Researchers have also tried injecting chemical agents such as verapamil, collagenase, steroids, and interferon alpha-2b directly into the plaques. Verapamil and interferon alpha-2b seem to diminish curvature of the penis. The other injectable agent, collagenase, is undergoing clinical trial and results are not yet available. Steroids like triamcilone have caused loss and atrophy of the local tissues and weakening of the tunica. The surgical planes also become difficult after steroid injection.
The intralesional injections are given with 24 G needle making multiple passes through the plaque.There is a possibility that the multiple passes make the plaque weak by mechanical disruption.
Intralesional Therapy:
1) Intralesional Verapamil
Dose 10 mg verapamil/4ml+6mlsaline total 10 ml ;2 weekly for 12 injections
Promising but un proven
2)Intralesional interferon -alpha-2b
Dose: 1millon units 2 weekly for 12 injections
Placebo trial-ongoing
Possibly useful
3)Intralesional Steroids
Dose 40 mg triamcinolone /ml, dilute as per size 6 weeks total 6 injections
Steroids may weaken tunica loss of surgical planes due to trauma

IDIOPATHIC OLIGOSPERMIA :MANAGEMENT

Despite advances in diagnostic modalities up to 25% patients exhibits unexplained infertility. A variety of medical therapies have been suggested to treat this group. However none of these have sown effective to be repeated controlled trials. A meta-analysis of all controlled studies for idiopathic male infertility has failed to reveal significant efficacy of currently available treatment .In the hope that they may be effective in a selective group of people a minimum of 3-6 months trial should be given to include at least one cycle of spermatogenesis
The empirical therapy includes the following drugs:
1) Hormonal agents (direct or rebound effect):The testosterone undecanoate 80-160mg/d, Testosterone enanthate or propionate inj 2-3 weekly Side effects: Azoospermia ,gynecomastia, cholestasis and hepatic dysfunction

2) Antiestrogens : Clomiphene citrate 25-50 mg daily, Tamoxifen 10-30 mg daily, Side –effects: nausea, weight gain loss of libido, headache ,gynecomastia, dermatitis.

3)Antioxidants: The oligospermia is many a times attributed to Reactive Oxygen Species.Various agents are prescribed to nullify the effects of Reactive Oxygen Species like glutathione,Lycopene-4mg/d, Vitamin E 400-800mg/d,N-Acetyl Cysteine 1000 mg/day.
4)Sperm vitalizers : Cellular Energisers like L-Arginine,Zinc, Selenium, proanthrocyanidin , Carnitine 1-2 mg/d CoQ10 10-400mg/d,Pentoxiphylene

If this is unsuccessful ,Assisted Reproductive Technique (ART) is employed or a combined approach may be started simultaneously in older couples.

Specific medical therapy in oligospermia:
Chronic fungal dermatitis
Anti fungal topical cream For ex.Candid B ointment locally

Chronic filarial epididymo-orchitis
Anti filarial &anti-inflammatory drugs-Hetrazan 100 mg three times a day for 3 weeks
Seminal Infections:-
Whether infection causes infertility is still controversial. There are several conflicting reports of benefit of treatment. The semen analysis showing plenty of pus cells should be discussed with the seminologist so as to remove any confusion of round cells with immature spermatogonia. Semen culture should be done in such cases.The common seminal organisms are:Streptococcus fecalis,E coli,Coagulase +ve staph (albus) or Occasionally Klebsilla , proteus,pseudomonas. Ciprofloxacin/doxycyclins can be administered as per the semen culture sensitivity report for a period of 4-6 weeks. As a rule, both sexual partners should be treated at the same time.In the mean time condom intercourse can be performed. At the end of the treatment it should be confirmed that infection is eradicated as there is tendency for chronicity

Antisperm antibodies: The direct test should be done for ASA and if present should be treated on priority with Intra-Uterine Insemination.The other modality of treatment is giving prednisolone 5 mg three times a day for 3-12 months.

Management of hypogonadotrophic hypogonadism:
Management delayed puberty: No initiation of puberty by age 13 in girls and 14 in boys
Delayed puberty Management
Injection testosterone esters are given in the strength of 50-100mg per month for 3-6 months.This This dose will advance puberty without impairing height potential.The spontaneous onset of puberty should be awaited for 3-6 months if there is no initiation formal testosterone replacement therapy should be given.
Management of pre pubertal Hypogonadotropic Hypogonadism

The treatment should be based on androgenising the patient. So it is usually done by giving testosterone or HCG.

Testosterone Replacement Therapy for Androgenisation:
Inj Sustanon deep IM in the following protocol:to start with 100 mg deep intramuscular every month for 3 months.This dosage is progressively increased to 250 mg once a month followed by 250 three weekly for long term treatment. When fertility is desired LH and FSH support is usually given with proper counseling as the cost of the therapy may be 2-3 lakhs with 50 % chance of conception.
The underlying principle is to achieve initial testicular growth with LH (LH is given as HCG. 5000 u one injection per week , 2000 u two to three injections per week.HCG dose monitoring is done by assaying testosterone on Day 3(for response) and Day 7(for sustenance).Testicular volume is monitored along with the signs of androgenisation. When testicular volume become 18 ml and ejaculation starts then FSH are added to complete spermatogenesis.FSH is started in the form of HMG
Dose options:37.5 units thrice-a-week/75 u thrice-a-week/150 u thrice-a-week
This is continued till pregnancies occur. The count may increase from azoospermia to 5-10 millions/ml so Assisted Reproductive Technology may be needed.Testosterone is restarted after pregnancy is over.

Drugs Therapy in Premature Ejaculation
Local anaesthesia: Topical anesthetics/gel are sometimes given with the idea of desensitizing the glans and delaying the orgasm. Lignocaine cream can be given for application for 20 minutes before the sexual act.
Medications:
Normally Selective Serotonin Uptake Inhibitors are used for such patients along with psychotherapy. The mechanism of action of SSRIs is linked to their inhibition of neuronal uptake of serotonin in the CNS. They prolong the sexual climax causing relief from early unwanted ejaculation.
These SSRI (Sertraline,Paroxetene.Fluoxitine)may take until at least 3 weeks following initiation of treatment to cause improvement in sexual latency.
Dose of the medications:
Clomipramine (clonil) 10-25 mg
Paroxetine(parotin) 10-20 mg
Sertaline (sertima) 25-100 mg
Fluoxetine(prodep) 20-40 mg
These drugs may cause side effects like yawning,anejaculation,decreased libido,perspiration and increased fatigue.

It has been seen that many patients with PE have undelying erectile dysfunction also so adding PDE-5 inhibitors like Viagra(sildenafil),Tadalafil works well.
Dapoxetine is an SSRI developed specifically for the treatment of premature ejaculation. Dapoxetine may be effective at first dose (ie, on-demand) for premature ejaculation when given 1-3 hours prior to sexual intercourse.
The optimal medical treatment for premature ejaculation has not been established but single dosing prior to sexual relations can work for many males.While raised blood levels through daily use of the medication may be unnecessary resulting in many CNS side effects. Obviously, if single dosing is successful, therapy is simpler and is associated with fewer adverse effects. Therefore, this may be the preferred initial therapy.
Dapoxitine right now although is manufactured in India ;is not available in market.But it soon expected after Food Drug Administration approves it.

Dosage of the testosterone and diagnostic evaluation:
The level of total testosterone below < 200-250 ng/dl of total testosterone /,8 nmol/L total testosterone or <3.8nmol/L bioavailable testosterone/<0.255 nmol/L free testosterone is indicative of low testosterone level. The actual threshold will vary as per previous levels life styles and habits.
Various types of testosterone replacement:

Testosterone therapy injectable
· Testosterone enanthate (testoviron depot)200-400 mg/4 weekly deep IM
· Mixed testosterone esters (sustanon) 250 mg/3 weekly deep IM
Highly effective inexpensive but causes Wide variations in level so the effect can be erratic like mood variations in the patient.

Oral
Testosterone undecoate (andriol)160mg/day. It should be taken
after full meals.

Gel
Available in 5g to 10g sachets. It is applied to shoulders and chest. After application 15-20 minutes are allowed to dry. The patient should avoid bath or swimming for 6 hours there after. The gel causes physiological levels to be attained without variations. The side effects are skin rash in some.

Spray
4-6 sprays every day. It is applied to shoulders and chest. After application 5 minutes should be given for application. The patient should avoid bath or swimming for 6 hours thereafter as in gel. The gel causes physiological levels to be attained without variations.

Adjusting dose schedule:
Check testosterone level before using the 30 week dose
Testosterone level recommended dosing interval
10-15 nmll/L continue at 12 weekly intervals
<10nmol/L continue at 10 weekly intervals
<15 nmol/L continue at 14 weekly intervals

a)Monitoring during testosterone therapy

b) Monitor for response: Primarily symptomatic, there will be increase in libido, energy and feeling generalized well being. The erectile dysfunction will start resolving. Generalised muscle strength as witnessed by handgrip and cognition will also improve.Bone density will also increase.

c) Monitor for complications: Hyperviscosity syndrome, increase in RBC mass,so complete blood count and hematocrit should be monitored. If hematocrits increase more than 55% then therapy should be stopped. There is a risk of exaggeration of pre-existing carcinoma prostate. The therapy as such doesnot increases the risk of prostatic malignancy. The risk of sleep apnea syndrome is increased as the central response to CO2.Liver Function tests also may deteriorate so need to monitor LFT,PSA,Hematocit.

Peyronies disease

2010-08-26T20:29:00.000-07:00

Peyronie’s Disease

Peyronie’s disease is characterized by a plaque, or hard lump, that forms within the penis. The plaque, a flat plate of scar tissue, develops in the tunica albuginea part of the penis, which is a covering of the erectile tissues. This condition was described by Fallopius in 1561 and popularized by Gigot de la peyronie in 1743.
The average age of onset of the disease is 53 years and its prevalence is 3.2% in sexually active men.

Presentation:
Cases of Peyronie’s disease range from mild to severe. Symptoms may develop slowly or appear overnight. In severe cases, the hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection. In many cases, the pain decreases over time, but the chordee may remain a problem, making sexual intercourse difficult. The sexual problems that result can disrupt a couple’s physical and emotional relationship and can lower a man’s self-esteem. Natural history of the disease goes through an active phase of painful erection and changing plaque configuration followed by a secondary phase of painless deformity and progressive calcification. The disease is progressive in 30-40% cases and stable in 40-50% but the spontaneous resolution is rare.

About 30 percent of men with Peyronie’s disease develop other fibrotic disorders as Dupuytren’s contracture of the hand. Familial association,diabetes and urethral instrumentation are other causes for Peyronies disease.

Pathophysiology:

The trauma is believed to be central reason behind the Peyronies disease.The trauma to the penis causes buckling of the area of the attachment of the central septum with the tunica albugenia causing rupture of the blood vessesls. The hematoma is accompanied by the accumulation of the inflammatory mediators. The Peyronies disease goes through three stages:
Step 1: Inflammatory exudates between cavernosa and albuginea consisting of Lymphocytes macrophages, plasma cells which secrete Active cytokines TGF ß1 .The TGF ß1 increases collagen synthesis, proteoglycans, fibronectin

Step 2: Fibrous infiltration of the sub tunical layer
Step 3: Extensive localized fibrosis and ossification
The plaque causes chordee and venous leak which causes erectile dysfunction. iNOS deficiency is also supposed to be cause behind erectile dysfunction.

Diagnosis:
Doctors can usually diagnose Peyronie’s disease based on a physical examination. The plaque can be felt when the penis is limp. The erection may be induced by injecting intracavernosal papavarine or bimix and an Doppler ultrasound scan of the penis to pinpoint the location and calcification of the plaque and concomitant venous leak may be done. A photograph may be taken to document the angle of chordee prior to surgical treatment.

MEDICATIONS:
The goal of therapy :
1) To restore and maintain the ability to have intercourse.
2) To decrease the pain
3) To allay the fears in mind of the patient and re-educate him about the disease.
4) To restore cosmetic appearance
Experts usually recommend surgery only in long-term cases in which the disease is stabilized and the deformity prevents intercourse.
Medical Treatments
Various medications like Vit E 400 mgs three times a day for 3 months, Cochicine 0.5 mg 2 bd for 3 months or Tamoxifen 20 mg BD for 3 months.The placebo controlled trioals have not shown efficacy of the medications but colchicines there are no placebo studies. It seems to be effective.

Researchers have also tried injecting chemical agents such as verapamil, collagenase, steroids, and interferon alpha-2b directly into the plaques. Verapamil and interferon alpha-2b seem to diminish curvature of the penis. The other injectable agent, collagenase, is undergoing clinical trial and results are not yet available. Steroids like triamcilone have caused loss and atrophy of the local tissues and weakening of the tunica. The surgical planes also become difficult after steroid injection.
The intralesional injections are given with 24 G needle making multiple passes through the plaque.There is a possibility that the multiple passes make the plaque weak by mechanical disruption.
Surgery
Three surgical procedures for Peyronie’s disease is done for curvature more than 45 degrees in angle making sexual intercourse difficult.Various procedures have been followed like placation(problem of further shortening penis),incision or excision and grafting(tunica vaginalis or saphenous vein graft) or implantation of penile prosthesis.
If the implant alone does not straighten the penis, implantation is combined with one of the other two surgical procedures.

ROLE OF ROBOTIC SURGERY IN ANDROLOGY

2010-08-26T20:28:00.000-07:00

Robots To Cure Male Infertility
Recent studies have shown that Male Infertility is on the Rise due to decrease in average sperm count, as we are step into the 21 st century.
This can be attributed to genes, infections, life style changes, smoking, drug abuse, mental stress due to pressures at work, obesity, hypertension, and environmental and pesticide pollutants. This means more and more males will become infertile and will have to resort to medical, surgical and Assisted Reproductive Treatment to help their partners conceive

Over the past 30 years, the treatment of infertility has seen the development of revolutionary new assisted reproduction techniques like In-Vitro Fertilisation (IVF) and Intra-Cytoplasmic Sperm Injection (ICSCI)
These highly complex techniques are used with increasing frequency in the treatment of couples around the globe.
More than 1 million babies worldwide have been conceived by these new techniques giving immense satisfaction to infertile couples.
Both IVF and ICSCI involve conception in a Test Tube and hence bypass natural conception. There is therefore a risk of undesirable genetic traits being passed on to next generation.
IVF and ICSI are also advised in Males who have a poor sperm count and in whom medicine or surgery cannot help to improve the sperm count.
Recent technological advances have enabled the use of Robotics and Micro Surgical assisted techniques to improve sperm counts. This helps conception in a more natural form and avoids the use of IVF and ICSCI when the Male is responsible for the lack of conception in an infertile couple
The infertile males either have a low sperm count ( due to inadequate sperm production also known as Oligospermia) or have no sperms in the semen (Azoospermia) .

When Azoospermia is due to a block in the tubes (Epididymis, Vas Deferens, Ejaculatory Duct) transporting the sperm it can be cured surgically by advanced techniques called VasoVasostomy, VasoEpididymoAnastomosis or Seminovesiculoscopy. These surgeries are very delicate and time consuming as they involve operating on structures smaller than the heart vessels.

With advances in MicroSurgery and Robot Assisted MicroSurgery the chance of sperm (re) appearance rate can be as high as 80%.. Without the use of these techniques the chances of sperm (re)appearance is as low as 5 %.
Robotic vasectomy reversal
The advantage of microsurgical reconstruction is that once successful, natural conception is possible time and again without the mental agony of going through multiple IVF or ICSCI cycles apart from the huge recurring costs.
Multiple data from leading centers all over the world have proven the cost effectiveness of Microsurgical and Robotic Microsurgical reconstruction over the routine sperm retrieval for IVF and ICSI.

In oligospermia (Low Sperm Count) due to poor sperm production either due the enlarged veins surrounding the testes
( Varicocele), microsurgery allows a success rate of almost 60% (pregnancy rate).

In cases where the low sperm count is due to disease in the testes Microsurgical Sperm Retrieval (Micro-dissection TESE) techniques can find sperm in Testis.
In conclusion recent advances in Robotics and MicroSurgical Techniques have given new hope to an infertile male to conceive in a natural way.

Empty scrotum:management strategy

2010-08-26T20:27:00.000-07:00

Empty Scrotum

Cryptorchidism is a common disorder in pediatric urology. It has been observed to occur in 3% of term infants and 30% of premature infants; however, 75% and 90% of these undescended testes, respectively, will have spontaneously descended by age 1 year, leaving a true incidence of close to 1% (0.8%) of the male population. Ten percent of cases are bilateral, 3% of which will have one or both testes absent. The etiology is unclear, and although many genetically inherited diseases have a high association with cryptorchidism, most cases of the undescended testis are isolated with no evidence of a genetic component.

SIGNIFICANCE
· A 33-fold increased risk of developing a testicular malignancy has been noted with undescended testes.
· Ten percent of testicular cancers arise in an undescended testis, 60% of which will be seminomas.
· The intraabdominal testis is four times more likely to undergo malignant degeneration than is an inguinal testis.
· Fertility is impaired. Only 30% of patients with bilateral cryptorchidism even after the surgery will be fertile. Spermatogenic damage appears to increase with higher position and longer periods of extrascrotal habitation.
· A high incidence of associated inguinal hernias (30%) occurs because of the patent processus vaginalis.
· An increased susceptibility to torsion exists, especially in postpubertal period.
· An increased susceptibity for trauma.

CLASSIFICATION
· Intraabdominal (10%)—testis is located proximal to the internal inguinal ring within the abdominal cavity.
· Inguinal canal—testis is located between internal and external intuinal rings.
· Ectopic—testis is located distal to the internal ring but outside its normal path of descent. Most are found in the superficial inguinal pouch or in perineum, femoral canal, suprapublic area, and, rarely, in the contralateral scrotal compartment.
· Absent testis (4%)—20% of nonpalpable testes are absent.
· Retractile testis—testis is not truly undescended. Its extrascrotal location is secondary to hyperactive contraction of the cremasteric muscle. It is commonly found in the prescrotal or low inguinal area and with gentle manipulation can be placed in the scrotum without tension.

DIAGNOSIS
Carefully palpate both scrotal compartments, the inguinal canals, perineum, suprapubic area, and femoral canal. A palpable testis will be inguinal, ectopic, or retractile. If the testis can be easily placed within the scrotum without tension, it is retractile. Note that the cremasteric reflex is most active between ages 2 and 7 years, making this diagnosis difficult. A nonretractile palpable testis is either inguinal or ectopic.
A nonpalpable testis is either intraabdominal, ectopic, inguinal, or absent. If both testes are impalpable, then measure serum testosterone response to human chorionic gonadotropin (HCG) stimulation (HCG 2,000 IU daily 3days) and basal follicle-stimulating (FSH) and luteinizing hormone (LH) levels. A negative testosterone response to HCG and elevated basal FSH and LH levels are reliable evidence of anorchism (bilateral testicular absence). Bilateral or unilateral non palpable nondescensus can be further investigated by ultrasound, computed tomography, laparoscopy, and surgical exploration. Most testes will be found at surgery close to the internal inguinal ring.

TREATMENT

Why Treat Undescended Testis?
· The surgery will not reduce the malignancy occurrence chance but certainly it will make the testis more easily palpable for the patient and the surgeon.
· To repair inguinal hernias(30% patients have chance of co-existing hernia)
· To decrease risk of torsion
Therapy should be undertaken between ages 6 and 18 months. This will allow adequate time for spontaneous descent to occur and should minimize the potential complications of infertility and malignant degeneration. Retractile testes need no further therapy; however, periodic reexamination to confirm the diagnosis would be prudent. The truly undescended testes can be treated with either hormonal or surgical therapy or both.

Hormonal Therapy

HCG has been used to bring down the testis in up to 70% patients, respectively. Hormonal therapy is contraindicated with ectopic testes, in the setting of a hernia, and after prior orchiopexy or herniorrhaphy (because of the scarring).

Surgical Therapy

Several different procedure for orchiopexy are effective, all based on the principles of adequate mobilization and fixation and repair of the associated hernia in one stage or in two stages.
Occasionally, greater mobilization of the proximal spermatic cord structures does not provide adequate length to allow for tension-free placement of the testis within the scrotum. Greater cord length can be obtained by mobilizing the spermatic vessels medially. The spermatic vessels are usually the limiting factor in these circumstances. The Prentiss maneuver was described in 1960 and is occasionally helpful in adding length to the spermatic vessels by positioning the spermatic vessels medially and thereby choosing the hypotenuse of the triangle, or the most direct course to the scrotum, created by the natural course of the vessels laterally through the internal ring. It is performed by incising the floor of the inguinal canal through the external ring and dividing the inferior epigastric vessels. The internal ring and transversalis fascia are then closed lateral to the cord.
Ligation of the testicular vessels occasionally becomes a necessary consideration, especially in the management of a high inguinal or intra-abdominal testis. The technique described by Fowler and Stephens was originally a one-stage procedure, but it may also be performed in two stages. If a one-stage repair is to be performed, it is critical early in the dissection that a wide pedicle of peritoneum be preserved with the vas deferens to maintain collateral blood flow.
Orchiectomy should be performed if the testis is atrophic and cannot be brought to the scrotum.

Surgery for Erectile Dysfunction

2010-08-25T06:37:00.000-07:00

Surgery
Surgery usually has one of three goals:
to implant a device that can cause the penis to become erect (Penile Implant surgery)
to reconstruct arteries to increase flow of blood to the penis (Penile revascularization surgery for patient with focal arterial stenosis-post-trauma)
to block off veins that allow blood to leak from the penile tissues (penile venous leak-particularly detected on Doppler showing persistence end-diastolic velocity more than 5 cm/sec)
Implanted devices, known as prostheses, can restore erection in many men with ED. The patient who donot respond to intracavernosal injection of vasodilator agents or Vacuum Erection Device. Neophallus reconstructed patient are also candidates for penile implant surgery. The contra-indications for the penile implant are uncontrolled diabetes,spinal cord injury patients, patients with severe psychiatric imbalance, neurogenic bladder and very short penis. The implant gives erection with causing some decrease in length so this thing has to be emphasized to the patient before the surgery.
Types of penile prosthesis are:
Non-inflatable(Malleable,hinged prosthesis)- less costly but gives constant erection and needs special clothing for concealment of the erection.
And
Inflatable(2 piece and 3 piece variety):Expensive,surgery is technically demanding but gives near to normal erection.

Choice of three piece implants

700CX: Diameter 12 to 18 mm length constant
700 ultrex: Girth 12 to 18 mm, length increases.So to a patient concerned about the length of the penis post implant this is a good choice.
700 with inhibizone coating

Description of inflatable implant:
Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis. They also leave the penis in a more natural state when not inflated.
Advantages with the penile impants are:
o Good rigidity
o Freedom from medications
o Outpatient/24HR surgery
o Resume sexual activity 4-6 weeks
o No loss of ability to ejaculate or achieve orgasm

Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to perineum or fracture of the pelvis.Surgery to veins that allow blood to leave the penis usually involves an opposite procedure-intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood that diminishes the rigidity of the penis during erection. However the results are not long lasting so the venous ligation surgery have diminished

PHOTOGRAPHS OF PENILE IMPLANT SURGERY BEING DONE

COMPLICATIONS OF PENILE IMPLANT:
Infection (5-14%)
Infection in the periprosthetic space usually does not cause significant illness; however, to eradicate the infection, removal of all components of the prosthesis is almost always required.
Infections occurring after penile prosthesis implantation are either early (in the first few weeks following implantation) or late (6 months to 1 or 2 years after implantation). The former are often associated with gram-negative bacteria, whereas the later are usually associated with gram-positive bacteria such as Staphylococcus epidermidis. Early infections are usually acquired during the surgery. 56% of cases occur within 6 months, 36% occu within 7-12 months and 2.3% after 5 months.
Pre-operatively cephalosporins and aminoglycosides should be administered and post-operatively quinolones should be given.
Early infections are likely to be evident by swelling, erythema, tenderness, possible purulent drainage, and occasionally fever. Late infections may be manifested only by persistent or recurrent long-term pain. With long-term infections the scrotal skin may be adherent to the pump.
Treatment of a prosthetic infection with appropriate antibiotics usually results in clinical improvement; however, antibiotic treatment rarely permanently eradicates this type of infection. This is thought to be due to harboring of microorganisms within a biofilm that is adherent to the device. For this reason, when a prosthetic infection is present, all components of the prosthesis should be removed.The corporal spaces should be lavaged with antibiotic solutions. Vancomycin and Gentamycin should be used for lavage.
After the infection has come into control usually in the interim period the Vacuum Erection Device should be encouraged.The advantage being the VED will cause stretching the corpora and to certain extent increase the length and the girth of the penis and cause easier dilatation during the second surgery.
When all incisions have healed and postoperative edema has resolved (usually 2 to 3 months after device removal), reimplantation is advised because early fibrosis is easier to dilate and the scar contraction that leads to shortening has not yet occurred.
New Inhibizone Implants have come with antibiotics-Rifampicin and Minocyclin.
Perforation and Erosion
Perforation is an event that occurs intraoperatively; whereas erosion is an event that occurs or is recognized only postoperatively. When the surgeon is dilating the proximal corpora (crura), a sudden give of the dilator suggests that the crus has been perforated on its medial aspect near its attachment to the pelvic bone. The dilator, almost always a smaller size, travels out into the soft tissues of the perineum. Mulcahy suggested the “wind sock” correction for this, but it is rarely necessary if the perforation is recognized and larger diameter dilators are used to dilate the correct track. When the proximal portion of the cylinder is inserted, it stays within the crus and the small area of perforation heals over it.
With distal dilation, crossover to the opposite side may occur or the urethra may be perforated. If urethral perforation occurs, the implant procedure should be abandoned and a urethral catheter should be left in for 7 to 10 days. Prosthesis reimplantation may be done at a later date. To avoid urethral perforation, the surgeon should keep the tip of the dilator under the dorsolateral surface of the corpus cavernosum. This maneuver also helps to prevent crossover to the opposite side. After the first cylinder is implanted, the surgeon should resound the other side both proximally and distally to see whether crossover in either direction has occurred.
Erosion of the distal end of the prosthesis may occur into the urethra, in which case it is visible through the meatus. This occurs more commonly after semirigid rod implantation, presumably because of constant internal pressure from the rod device. It also occurs more commonly in men with spinal cord injury because of their lack of sensation. In the case of urethral erosion, a urethral catheter is placed for 10 days to allow urethral healing. Many patients are able to have adequate coitus with only one rod in place; hence, a procedure to reimplant the second rod is usually not necessary.
Poor Glans Support
Poor support of the glans penis by cylinder or rod tips leads to a drooping appearance of the glans, which is commonly referred to as the SST deformity after the supersonic transport (Concorde) nose appearance on takeoff and landing. This deformity may result from inadequate distal dilation, too short cylinders, or, in the case of minor deformity, variations in anatomy.
Correction of this deformity can be done in one of two ways. The definitive correction involves removing both cylinders, perforating the distal capsule with Metzenbaum scissors, redilating the distal corpora, resizing, and then inserting longer cylinders or the same cylinders with longer rear tip extenders. Alternatively, dorsal plication of the glans back onto the shaft of the penis can be performed. The latter procedure is preferable when there are minor but otherwise bothersome degrees of SST deformity.

Pump Complications
The technique for pump implantation discussed previously helps to avoid upward pump migration, which tends to take place during healing because of the action of the cremasteric muscles. If upward pump migration occurs, the pump may impinge on the base of the penis, making use of the pump difficult and also interfering with intromission. Revision is sometimes necessary, at which time the pump is relocated to its correct position.
The pump may also be difficult to use if a hematoma or seroma forms around it. These may reabsorb with time; if they do not, pump revision may be necessary.
Autoinflation
Autoinflation occurs when the inflatable penile prosthesis partially inflates with physical activity. It can be minimized by placing the reservoir in the prevesical (retropubic) space and by performing the back pressure test as described previously. The cylinders should also be kept deflated during healing after surgery and when the prosthesis is not being used.
Mentor has a reservoir with a lock-out valve available as an option. Initial experience with this device suggests that it reduces the incidence of this complication.

Medical Management of erectile dysfunction

2010-08-25T06:35:00.000-07:00

MEDICAL MANAGEMENT OVERVIEW IN ANDROLOGY:

ERECTILE DYSFUNCTION:

Pharmacotherapy of ED could intervene in the CNS: ALPHA 2 ADRENERGIC BLO0CKERS (YOHIMBINE,PHENTOLAMINE)and dopaminergic antagonist (APOMORPHINE ) or peripherally agents that enhance , elevate or directly stimulates the synthesis of secondary messenger molecules such as c AMP or c GMP and direct activators of adenylate cyclase for ex: Phosphodiesterase inhibitors :non selective –papaverine, Type 5 –sildenafil citrate,vardenafil,Tadalafil,Type 3 Milirinine and Type 4 roliparm
Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra at the tip of the penis. In March 1998, the Food and Drug Administration (FDA) approved Viagra, the first pill to treat ED. Since that time, vardenafil hydrochloride (Levitra) and tadalafil (Cialis) have also been approved. Additional oral medicines are being tested for safety and effectiveness. Viagra, Levitra, and Cialis all belong to a class of drugs called phosphodiesterase (PDE) inhibitors. Taken an hour before sexual activity, these drugs work by enhancing the effects of nitric oxide, a chemical that relaxes smooth muscles in the penis during sexual stimulation and allows increased blood flow.While oral medicines improve the response to sexual stimulation, they do not trigger an automatic erection. The recommended dose for Viagra is 50 mg, and the physician may adjust this dose to 100 mg or 25 mg, depending on the patient. The recommended dose for tadalafil(Megalis,Forzest) is 10 mg, and the physician may adjust this dose to 20 mg if 10 mg is insufficient. A lower dose of 5 mg is available for patients who take other medicines or have conditions that may decrease the body's ability to use the drug.
None of these PDE inhibitors should be used more than once a day. Men who take nitrate-based drugs such as nitroglycerin for heart problems should not use either drug because the combination can cause a sudden drop in blood pressure. Also patients have severe cardiac diseases like recent Myocardial Infarction, reduced stress tolerance should avoid PDE-5 inhibitors.

sildenafil
tadalafil
verdenafil
Maximum plasma concentration
30-120 (median 60)
30-360 (median 120)
30-120 (median 60)
Half life hours
4
17.5
4-5
Duration of action
up to 4-12
up to 36
Up to 4-12
Food restriction
may take longer to work with meals
can be taken with or with out food
can be taken with or without fatty foods
INTRA CAVERNOSAL INJECTION OF VASO ACTIVE DRUGS (ICIVAD)
Many men achieve stronger erections by injecting drugs into the penis, causing it to become engorged with blood. Drugs such as papaverine hydrochloride(15- 60 mg), phentolamine, and alprostadil (marketed as Caverject) widen blood vessels. These drugs may create unwanted side effects, however, including pain (36%) persistent erection (4%) and scarring. It gives a success rate of 70-90 % but these injections have a drop-out rate of 25-60% because of mainly pain or sometimes development of corporal fibrosis.
Methodology of giving papavarine/bimix:
Start with 29-30 G Insulin syringe for the injection therapy.

Papavarine:It can be started with 15 and given till 60 mg. Inject in any corpus.
Bimix: Add chlorpromazine ( 4 ml papavarine to 0.1 ml chlorpromazine combination) start with 0.1 to 0.2 ml and then gradually increased .Again the injection can be given in any one of the corpus
Drug therapy for Peyronie’s disease:
Medical Treatments
Various medications like Vit E 400 mgs three times a day for 3 months, Cochicine 0.5 mg 2 bd for 3 months or Tamoxifen 20 mg BD for 3 months.The placebo controlled trioals have not shown efficacy of the medications but colchicines there are no placebo studies. It seems to be effective.

Researchers have also tried injecting chemical agents such as verapamil, collagenase, steroids, and interferon alpha-2b directly into the plaques. Verapamil and interferon alpha-2b seem to diminish curvature of the penis. The other injectable agent, collagenase, is undergoing clinical trial and results are not yet available. Steroids like triamcilone have caused loss and atrophy of the local tissues and weakening of the tunica. The surgical planes also become difficult after steroid injection.
The intralesional injections are given with 24 G needle making multiple passes through the plaque.There is a possibility that the multiple passes make the plaque weak by mechanical disruption.
Intralesional Therapy:
1) Intralesional Verapamil
Dose 10 mg verapamil/4ml+6mlsaline total 10 ml ;2 weekly for 12 injections
Promising but un proven
2)Intralesional interferon -alpha-2b
Dose: 1millon units 2 weekly for 12 injections
Placebo trial-ongoing
Possibly useful
3)Intralesional Steroids
Dose 40 mg triamcinolone /ml, dilute as per size 6 weeks total 6 injections
Steroids may weaken tunica loss of surgical planes due to trauma

IDIOPATHIC OLIGOSPERMIA :MANAGEMENT

Despite advances in diagnostic modalities up to 25% patients exhibits unexplained infertility. A variety of medical therapies have been suggested to treat this group. However none of these have sown effective to be repeated controlled trials. A meta-analysis of all controlled studies for idiopathic male infertility has failed to reveal significant efficacy of currently available treatment .In the hope that they may be effective in a selective group of people a minimum of 3-6 months trial should be given to include at least one cycle of spermatogenesis
The empirical therapy includes the following drugs:
1) Hormonal agents (direct or rebound effect):The testosterone undecanoate 80-160mg/d, Testosterone enanthate or propionate inj 2-3 weekly Side effects: Azoospermia ,gynecomastia, cholestasis and hepatic dysfunction

2) Antiestrogens : Clomiphene citrate 25-50 mg daily, Tamoxifen 10-30 mg daily, Side –effects: nausea, weight gain loss of libido, headache ,gynecomastia, dermatitis.

3)Antioxidants: The oligospermia is many a times attributed to Reactive Oxygen Species.Various agents are prescribed to nullify the effects of Reactive Oxygen Species like glutathione,Lycopene-4mg/d, Vitamin E 400-800mg/d,N-Acetyl Cysteine 1000 mg/day.
4)Sperm vitalizers : Cellular Energisers like L-Arginine,Zinc, Selenium, proanthrocyanidin , Carnitine 1-2 mg/d CoQ10 10-400mg/d,Pentoxiphylene

If this is unsuccessful ,Assisted Reproductive Technique (ART) is employed or a combined approach may be started simultaneously in older couples.

Specific medical therapy in oligospermia:
Chronic fungal dermatitis
Anti fungal topical cream For ex.Candid B ointment locally

Chronic filarial epididymo-orchitis
Anti filarial &anti-inflammatory drugs-Hetrazan 100 mg three times a day for 3 weeks
Seminal Infections:-
Whether infection causes infertility is still controversial. There are several conflicting reports of benefit of treatment. The semen analysis showing plenty of pus cells should be discussed with the seminologist so as to remove any confusion of round cells with immature spermatogonia. Semen culture should be done in such cases.The common seminal organisms are:Streptococcus fecalis,E coli,Coagulase +ve staph (albus) or Occasionally Klebsilla , proteus,pseudomonas. Ciprofloxacin/doxycyclins can be administered as per the semen culture sensitivity report for a period of 4-6 weeks. As a rule, both sexual partners should be treated at the same time.In the mean time condom intercourse can be performed. At the end of the treatment it should be confirmed that infection is eradicated as there is tendency for chronicity

Antisperm antibodies: The direct test should be done for ASA and if present should be treated on priority with Intra-Uterine Insemination.The other modality of treatment is giving prednisolone 5 mg three times a day for 3-12 months.

Management of hypogonadotrophic hypogonadism:
Management delayed puberty: No initiation of puberty by age 13 in girls and 14 in boys
Delayed puberty Management
Injection testosterone esters are given in the strength of 50-100mg per month for 3-6 months.This This dose will advance puberty without impairing height potential.The spontaneous onset of puberty should be awaited for 3-6 months if there is no initiation formal testosterone replacement therapy should be given.
Management of pre pubertal Hypogonadotropic Hypogonadism

The treatment should be based on androgenising the patient. So it is usually done by giving testosterone or HCG.

Testosterone Replacement Therapy for Androgenisation:
Inj Sustanon deep IM in the following protocol:to start with 100 mg deep intramuscular every month for 3 months.This dosage is progressively increased to 250 mg once a month followed by 250 three weekly for long term treatment. When fertility is desired LH and FSH support is usually given with proper counseling as the cost of the therapy may be 2-3 lakhs with 50 % chance of conception.
The underlying principle is to achieve initial testicular growth with LH (LH is given as HCG. 5000 u one injection per week , 2000 u two to three injections per week.HCG dose monitoring is done by assaying testosterone on Day 3(for response) and Day 7(for sustenance).Testicular volume is monitored along with the signs of androgenisation. When testicular volume become 18 ml and ejaculation starts then FSH are added to complete spermatogenesis.FSH is started in the form of HMG
Dose options:37.5 units thrice-a-week/75 u thrice-a-week/150 u thrice-a-week
This is continued till pregnancies occur. The count may increase from azoospermia to 5-10 millions/ml so Assisted Reproductive Technology may be needed.Testosterone is restarted after pregnancy is over.

Drugs Therapy in Premature Ejaculation
Local anaesthesia: Topical anesthetics/gel are sometimes given with the idea of desensitizing the glans and delaying the orgasm. Lignocaine cream can be given for application for 20 minutes before the sexual act.
Medications:
Normally Selective Serotonin Uptake Inhibitors are used for such patients along with psychotherapy. The mechanism of action of SSRIs is linked to their inhibition of neuronal uptake of serotonin in the CNS. They prolong the sexual climax causing relief from early unwanted ejaculation.
These SSRI (Sertraline,Paroxetene.Fluoxitine)may take until at least 3 weeks following initiation of treatment to cause improvement in sexual latency.
Dose of the medications:
Clomipramine (clonil) 10-25 mg
Paroxetine(parotin) 10-20 mg
Sertaline (sertima) 25-100 mg
Fluoxetine(prodep) 20-40 mg
These drugs may cause side effects like yawning,anejaculation,decreased libido,perspiration and increased fatigue.

It has been seen that many patients with PE have undelying erectile dysfunction also so adding PDE-5 inhibitors like Viagra(sildenafil),Tadalafil works well.
Dapoxetine is an SSRI developed specifically for the treatment of premature ejaculation. Dapoxetine may be effective at first dose (ie, on-demand) for premature ejaculation when given 1-3 hours prior to sexual intercourse.
The optimal medical treatment for premature ejaculation has not been established but single dosing prior to sexual relations can work for many males.While raised blood levels through daily use of the medication may be unnecessary resulting in many CNS side effects. Obviously, if single dosing is successful, therapy is simpler and is associated with fewer adverse effects. Therefore, this may be the preferred initial therapy.
Dapoxitine right now although is manufactured in India ;is not available in market.But it soon expected after Food Drug Administration approves it.

Dosage of the testosterone and diagnostic evaluation:
The level of total testosterone below < 200-250 ng/dl of total testosterone /,8 nmol/L total testosterone or <3.8nmol/L bioavailable testosterone/<0.255 nmol/L free testosterone is indicative of low testosterone level. The actual threshold will vary as per previous levels life styles and habits.
Various types of testosterone replacement:

Testosterone therapy injectable
· Testosterone enanthate (testoviron depot)200-400 mg/4 weekly deep IM
· Mixed testosterone esters (sustanon) 250 mg/3 weekly deep IM
Highly effective inexpensive but causes Wide variations in level so the effect can be erratic like mood variations in the patient.

Oral
Testosterone undecoate (andriol)160mg/day. It should be taken
after full meals.

Gel
Available in 5g to 10g sachets. It is applied to shoulders and chest. After application 15-20 minutes are allowed to dry. The patient should avoid bath or swimming for 6 hours there after. The gel causes physiological levels to be attained without variations. The side effects are skin rash in some.

Spray
4-6 sprays every day. It is applied to shoulders and chest. After application 5 minutes should be given for application. The patient should avoid bath or swimming for 6 hours thereafter as in gel. The gel causes physiological levels to be attained without variations.

Adjusting dose schedule:
Check testosterone level before using the 30 week dose
Testosterone level recommended dosing interval
10-15 nmll/L continue at 12 weekly intervals
<10nmol/L continue at 10 weekly intervals
<15 nmol/L continue at 14 weekly intervals

a)Monitoring during testosterone therapy
b) Monitor for response: Primarily symptomatic, there will be increase in libido, energy and feeling generalized well being. The erectile dysfunction will start resolving. Generalised muscle strength as witnessed by handgrip and cognition will also improve.Bone density will also increase.
c) Monitor for complications: Hyperviscosity syndrome, increase in RBC mass,so complete blood count and hematocrit should be monitored. If hematocrits increase more than 55% then therapy should be stopped. There is a risk of exaggeration of pre-existing carcinoma prostate. The therapy as such doesnot increases the risk of prostatic malignancy. The risk of sleep apnea syndrome is increased as the central response to CO2.Liver Function tests also may deteriorate so need to monitor LFT,PSA,Hematocit.

Nocturnal Penile Tumuscence Rigidity Test: Relevence in Erectile Dysfunction

2010-08-25T06:20:00.000-07:00

Nocturnal Penile Tumuscence Rigidity Test:
In its classic form, NPT consists of nocturnal monitoring devices that measure the number of episodes, tumescence , maximal penile rigidity, and duration of nocturnal erections. In 1985, the RigiScan was introduced; it was the first device to provide automated, portable NPTR recording. The device combines the monitoring of radial rigidity, tumescence, number, and duration of erectile events with the convenience of a portable system that can be used at home. It consists of a recording unit that can collect data for three separate nights for a maximum of 10 hours each night (As shown in above Figure). The mechanics consist of two loops: one is placed at the base of the penis and the other at the coronal sulcus. By constricting the loops, the device records penile tumescence (circumference) and radial rigidity at the penile base and tip. Radial rigidity above 70% represents a nonbuckling erection, and a rigidity of less than 40% represents a flaccid penis. The number of erections considered normal is three to six per 8-hour session, lasting an average of 10 to 15 minutes each. The normal NPTR criteria are: four to five erectile episodes per night; mean duration longer than 30 minutes; an increase in circumference of more than 3 cm at the base and more than 2 cm at the tip; and maximal rigidity above 70% at both base and tip.
The documented presence of a full erection indicates that the neurovascular axis is functionally intact and that the cause of the ED is most likely psychogenic.

Three Piece Penile Implant : Penile Erection almost simulating natural erection

2010-07-13T00:45:00.000-07:00

A 35 year old man came to us with psychogenic impotence.He had tried PDE-5 inhibitors,sex therapy and psychiatric medications for a long time.

He was also tried Vacuum Erction device and intracavernosal injections but did not benefit.
Finally was given option of penile implant .He chose a three piece Mentor Coloplast Implant.The surgery was done and the device was kept in semideflated position .He was instructed to come after 6 weeks for operation of the device.
Surgery usually has one of three goals:
to implant a device that can cause the penis to become erect (Penile Implant surgery)
to reconstruct arteries to increase flow of blood to the penis (Penile revascularization surgery for patient with focal arterial stenosis-post-trauma)
to block off veins that allow blood to leak from the penile tissues (penile venous leak-particularly detected on Doppler showing persistence end-diastolic velocity more than 5 cm/sec)
Implanted devices, known as prostheses, can restore erection in many men with ED. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of introduction of Viagra but there are a group of patients who fail with medications and refuse or fail with Vacuum Erection Device. Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis. They also leave the penis in a more natural state when not inflated.
Advantages with the penile impants are:
o Good rigidity
o Freedom from medications
o Outpatient/24HR surgery
o Resume sexual activity 4-6 weeks
o No loss of ability to ejaculate or achieve orgasm
Surgery to repair arteries can reduce ED caused by obstructions that block the flow of blood. The best candidates for such surgery are young men with discrete blockage of an artery because of an injury to perineum or fracture of the pelvis.Surgery to veins that allow blood to leave the penis usually involves an opposite procedure-intentional blockage. Blocking off veins (ligation) can reduce the leakage of blood

Post-enterocystoplasty massive bleeding because of Arteriovenous malformation from bowel arteries : A very Rare Case

2010-06-26T23:46:00.000-07:00

A 65 year old man presented to us with frank hematuria of 1 day duration. he was known case of small capacity bladder with hemorrhagic cystitis with no apparent reason.He was operated in 2002 for clam cystoplasty. He was apparently alright for 8 years just to land up in emergency department with gross total hematuria.He is known case coronary artery disease and hypertension on medication.He was on ecosprin when he came for hematuria.Immediately ecosprin was stopped.He was supported with irrigation,tranexa and cystoscopy and evacuation followed by alum irrigation.After this surgery he was fine for 2 days then suddenly he had bout of frank hemturia causing fall of Hb from 13 TO 10 GM% and BP to fall from 130/80 mm Hg to 70/30 mmHg.He was immediate taken up for cystoscopy and clot evacuation again with institution of proper blood support and plasma expander support.The bladder base region had angry looking globular mass? Rest of the bladder mucosa and the intestinal mucosa was normal.The clots were removed with resectoscope and cautery and ellicke evacuator.A three way Foleys catheter was introduced wnd alum irrigation was started..The urine effluent was clear.AFTER THE CLOT EVACUATION WAS DONE BILATERAL ANGIOEMBOLISATION WAS CARRIED OUT SELECTIVELY ON ANTERIOR DIVISION OF INTERNAL ILIAC ARTER USING SELDINGERS TECHNIQUE.

The both iliac arteries anterior divison was blocked with gel foam mixture viscous with the contrast,

The process of Angioembolisation of the internal iliac artery --the end result of the embolisation is seen as the disapperance of the terminal branches of the vesical arteries.The next plan was if the patient bleeds again then abdominal exploration.The patient again bleede after 5 days; again the bleed was torrential causing drop in hematocrit.

The patient was taken up for CT Angiography which showed a big arteriovenous malformation on the dome of the bladder feeded by superior mesenteric arteries.

the mesenteric artery being very crucial one the angioembolisation of it was not taken into consideration thinking of the sequele of catastrophe of mistaken blockage of main trunks.

The exploratotry laparotomy was performed.The adhesiolysis was performed.The dome of the bladder was thickened with multiple serpigenious vessels .This part of the bladder was excised and bladder was closed with Suprapubic tube in situ.

The abdomen was closed in layers with drain in pelvis.The post-operative period was uneventful with no episode of hematuria till 3 weeks post-operatively.

Free camp update

2010-06-26T22:01:00.000-07:00

First date of the Free Consultation camp for Male Infertility and Prostatic problems in general population was a great success with 78 patients visiting the Hospital and checked by the experts here.They got investigations at subsidised rates and medications for 15 days free of the cost.
Dr Ramesh Ramayya(CEO and Chairperson),Dr Vishwabhar Nath(Clinical Director),Dr Naveenchandra Acharya(Consultant Urologist),Dr Mahesh Sable(Medical Superitendent) supervised and managed the camp activities.

Press Conference by Dr Ramayyas Urology and Nephrology Hospital

2010-06-25T22:31:00.000-07:00

Dr Ramayyas Hospital arranged a press conference to spread awareness about the forthcoming health camp about male infertility and prostate problems in people.

Dr Vishwanbhar Nath(Clinical Director of Dr Ramayyas Hospital) and Dr Naveenchandra Acharya(Urologist and Andrologist)briefed about the male infertility and prostate issues to the conference.

The camp will be held at the Dr Ramayyas Hospital premises on 26 and 27 Th June from 10-4 pm.

Mitomycin C for prevention of bladder tumor recurrence

2010-06-25T22:18:00.000-07:00

A 30 year old lady presented with history of hematuria and dysuria. There was no history of comorbidities.

There was no history of prior surgical intervention .

On evaluation her USG showed left lateral wall space occupying lesion 3x2 cm and positive urine cytology for malignancy.

She was taken up for Trans-Urethal Bladder tumor resection with Continuous wave Holmium Laser.The Mitomycin C is a 334-kD alkylating agent that inhibits DNA synthesis. The drug is usually instilled weekly for 6 to 8 weeks at dose ranges from 20 to 60 mg.
One review found a 38% reduction in tumor recurrence with MMC.
Optimization of MMC delivery can result in halving of the recurrence rate in some studies. This can be achieved by eliminating residual urine volume, overnight fasting, using sodium bicarbonate to reduce drug degradation, and increasing concentration to 40 mg in 20 mL.

Check up camp for rnlarged prostate and male infertility

2010-06-25T21:06:00.000-07:00

We have arranged camp at Dr Ramayyas Urology and Nephrology Institute and Pramila Hospitals under patronage of Dr Ramesh Ramayya CE and chairman and able guidance of Dr Vishwambhar Nath.It will be kept on two days 26 and 27 th June 2010 from 10 am to 4 pm at the premises of the hospital.The patient can undergo tests worth 2500/- just for 700/- and free medications worth 15 days given.

Following symptoms - poor urine flow,urgency,frequency,night time frequent urinations,burning micturition,blood in the urine,prostate cancer and male infertility.The ejaculation problems will also be assessed and accordingly managed.

Dr Vishwambhar Nath(Clinical Director of the Hospital), Dr Naveenchandra Acharya(Andrologist) and Dr Mahesh Sable(Medical Superitendent) will be rendering their valuable services during the camp.

Post Papavarine Priapism

2010-06-25T01:09:00.001-07:00

A 28 year old patient came to us with priapism post papavarine induced for penile Doppler test.He presented to us five hours after the test.

On examination there was pain and considerable rigidity.

The patient was taken up for corporal drainage and instilllation of phenylephrine(1 ml PE in 19 ml Normal Saline).The corporal drainage was done with 21 G Vasofix and when dark blood was initially drained.When bright reddish blood started coming out PE was instilled.The final outcome was good, complete flaccidity was achieved.

The patient was kept on alprazolam and ketoconazole for 2 weeks to prevent erection.

Hypospadias repair

2010-06-25T00:37:00.001-07:00

A 10 year old man came with aberrhant opening of the urethra and chordee and small penis.

There were no other developmental anamolies.The testes were normally descended.

On examination there was distal penile hypospadias and chordee.

He was taken up for final single stage repair-after skin degloving the chordee was partially got corrected(this was tested by instilling saline in corpora through the glans).The urethra after degloving fell more proximally.

Tunica albugenia plication was done on lateral side then the chordee was totally corrected.The Tubularised Incised Plate Urethroplasty was done over silicon 10 Fr Foleys catheter.The dartos was used as covering flap and Byars flap was used to place skin coverage.

A 12 Fr Foleys catheter was kept as Supra-pubic tube.

Radical Cystoprostatectomy for bladder tumor

2010-06-25T00:06:00.000-07:00

A 60 year old man came to us with hematuria and lower urinary tract symptoms.On evaluation ultrasound revealed a space occupying lesion in bladder which was further evaluated with contrast enhanced CT scan.The CT scan showed huge bladder mass filling the almost bladder with left posterior and lateral wall thickening and the perivesical stranding.There were no obvious lymphadenopathy.

His metastatic work up was normal.He had no comorbidities except diabetes.He was taken up for Trans-urethral Bladder Biopsy which revealed Papillary Urothelial Neoplasm of Low Malignant Potential .As the growth was endoscopically unresectable there was high chance of muscle invasive element;the patient was counselled and taken up for Radical cystectomy and bilateral iliac lympahdenectomy and ileal conduit.The uretero-ileal anastomosis was done with Wallace technique.

Boari Flap reconstruction for upper ureteric stricture

2010-06-23T23:50:00.000-07:00

21 year old patient came to us with history of having been operated outside for ? twisted ovarian cyst. The laparoscopy was abandoned because contrary to their expectations they found retroperitoneal mass on the right side of the retroperitoneum.She came to us with a post-operative contrast enhanced CT Scan which revealed urinoma near middle of the right ureter

The urinoma was encapsulated in thick capsule (? Chronic process).On clinical examination she was looking ill and frail. She had loose motions(? Pelvic collection induced).Her vitals though were maintained except for tachycardia.She had normal hematological and biochemical parameters. Her abdomen was mildly distended with urinary leakage through one of the ports.She was taken up for Retrograde Pyelography which showed mid-ureteric disruption and dye leaking into a diffuse cavity.The patient was made prone for percutaneous nephrostomy drainage.Right Percutaneous Drainage was performed through a midcalyceal approach for possible antegrade stenting sometimes in future.She started draining around 100 ml of urine per hour through the nephrostomy and her leakage of urine through the port and the abdominal distension subsided.Her loose motions also subsided The very next day she started looking fresh and was back to her normal routine.She was called after a period of 6 weeks thinking that this time is enough for urinoma would subside and the inflammatory reaction would also subside.

She was taken up for laparotomy.A midline infra-umbilical incisiwas given .The bladder was capacious.
The ureter could be traced only till mid part.After that there was a massive fibrosis.The ureter was disconnected there and Boaris flap was raised from the bladder was anastomosed to the upper ureter after adequate spatulation.

The surgery was concluded with putting a stent in neo-ureter and supra-pubic tube in bladder.

Surgery for erectile dysfunction

2010-06-16T07:30:00.000-07:00

Testosterone undeconoate depot:better dosing conveniece

2010-06-03T00:35:00.000-07:00

We had one gentleman 56 year old complaining of loss of libido and decreased erection. He also complained about irritative mood and lack of enthusiasm. He was investigated and found to have a low testosterone level(230 ng/dl.)

He was started on testosterone local gel to be applied daily on his shoulder and after a period of 2 weeks; he underwent total and free serum testosterone assay again which was disappointedly low ( 268 ng/dl).

His erection had improved but not strong enough for penetration.He was also taking PDE-5 inhibitors along with hormone replacement.
He was now started on Testosterone undeconoate Depot 1000 mg/4ml deep intramuscularly as some patients have erratic absorption from local application.
The depot preparation would suit many patients as the injections can be placed at a wider intervals.For example we have scheduled the depot injection on 0,6th,18 th and 30 th weeks with Serum PSA and Complete Blood Parameters to be done on 18 th and 30 th weeks.
So there is convenience of administration as well 3-5 times lesser injections to achieve the sufficient testosterone in hypogonadal men.

Vacuum Erection Device

2010-05-25T07:44:00.000-07:00

A 34 year old man already married came to us with erectile dysfunction.After basic evaluation he was started on PDE-5 inhibitors but the result was sub-optimal.
He was then given option of Intra-cavernosal Injection therapy with Bimix but he was repulsive for any injection over the penis.
His basic cause for erection was psychological so we though the medications along with Vacuum Erection Device would be good as he is bound to recover with thecourse of the time.
He opted for battery opted device and is happy with the usage.His wife has also accepted the method whole heartedly.
Vacuum erection devices, also known as vacuum constriction devices have been utilized for improving erectile rigidity for ovrigidity of the penile erection.

The vacuum device consists of a clear plastic cylinder with an aperture at one end that is placed over the penile shaft ; extending till the base of the penis. At the other end of the cylinder is a pump mechanism that is used to generate negative pressure within the cylinder. The pump mechanism can be in the form of either a manually operated(Figure 1 ) or a battery-operated system(Figure 2).

The former requires two hands to operate the device, one on the pump handle and the other to steady the cylinder on the penis itself. So this device is better to be given for people relatively yound and having dexterity over the movements.
The battery-operated device can be used with one hand. This is a better device in relatively infirm patients with neurological weaknesses.
Technique
Once a decision has been made to pursue sexual relations, water-soluble jelly is applied to the base of the penis (As shown in Figure). This maneuver helps in creating a water-tight seal, thus maintaining the negative pressure within the cylinder.
The patient can shave of the pubic hair for better fitting of the instrument. Once the cylinder has been placed over the penile shaft and held firmly against the pubic bone, the pump mechanism can be activated (either by hand held or battery). The negative pressure (vacuum generation) will cause blood to be drawn in the corpora cavernosa. The negative pressure build up is gradual and slow to prevent bruises and hematoma and resultant pain.
Once the erection is achieved the pressure can be let off and again rebuilt to maximize the erection . Once the erection has been achieved, a constriction ring (band) is applied to the base of the penis to act as an artificial valve, thus maintaining the blood within the corporal bodies. The rings come in a variety of shapes, sizes, and most importantly tension (tightness). The choice of the ring depends upon the patients penile size,turgidity and the patients preference.
Indications:
The vacuum device is indicated for men with ED. Especially in older patient and with cardiac comorbidities who are not suitable for medications.The patients who donot improve with the medications also can respond to the Vacuum Erection Device.
It is best suited for the patients with co-operative partner who accepts the usage of the Vacuum Erection Device.
Contra-indications:
(i) using antiplatelet agents/or presence bleeding disorders
(ii) history of priapism
(iii) congenital penile curvature/peyronies disease
(iv) psychiatric disorders/neurological disorders
There are instances in older people mistakenly the Vacuum Erection Device has been applied over the testis also along with the penis and resultant gangrene of the testis.It may so happen that in an inebriated patient may forget to remove the ring after the sexual act.The patient having neurological deficit and no sensations over the penis may neglect ongoing hematoma or even may forget to remove the ring causing grave implications.
It is generally advised to keep ring for not more than 30 minutes.It is essential in old couple to involve both the partners so that such problems can be avoided.
Important Facts to remember:

It has been estimated that the surface temperature of the penis during use of the VED is lower than the temperature prior to application of the device. The patient and his partner should be counseled regarding this fact prior to the initial use of the device as some couple might find cool penis repulsive for the sexual act. The device can take around 15 minutes to obtain erection.This may sometimes kill the already awakened sexual excitement /arousal .
Side Effects
1)cool penis sensations
2)Penile hematomas/bruising
3)The penile numbness might develop in some patients
4)The penis may loosely hand beyond the ring.

Satisfaction:
Despite the apparent drawbacks to the use of vacuum devices, there is a population of patients who find its use easy and it has allowed many couples to successfully resume penetrative sexual relations. The satisfaction rate varies from 35-80% but there are drop outs because of the side effects or some couple opting for better alternatives like penile implants which tries to imitate the natural erection.This device is not good for young people who may feel embarrassed to do whole action-applying the Vacuum Erection Device ;creating the pressure and carrying it everywhere as cumbersome.

BOTOX: UTILITY IN UROLOGY

2010-05-23T23:09:00.000-07:00

Botox, which has been smoothing wrinkles for years, now it will also help in relief of the bothersome urinary symptoms associated with an enlarged prostate or bladder conditions.

Botulinum toxin (BTX), a neurotoxin produced by the gram-positive, rod-shaped anaerobic bacterium Clostridium botulinum, was isolated in 1897 by Belgian scientist Professor Pierre Emile van Ermengem. BTX acts by blocking the release of acetylcholine at the neuromuscular junction. As a result of this chemodenervation, a temporary flaccid paralysis ensues. Different medical disciplines have taken advantage of this temporary paralysis to treat muscular hypercontraction. BTX was first approved by the US Food and Drug Administration in 1989 for use in patients with strabismus and blepharospasm. Since then, BTX has been used to treat a number of different neuromuscular disorders. BTX has been used successfully in urology to treat neurogenic and non-neurogenic detrusor overactivity, detrusor-sphincter dyssynergia, motor and sensory urge, and chronic pain syndromes.
The BOTOX toxin is of various types:A to F.The BOTOX A is the more potent with greater duration of action.It has wide urological applications.The BOTOX will bind irreversibly to presynaptic membrane and cause skeletal muscle atrophy but the axons will regenerate after 3-6 months.
BOTOX has been used in many urological consitions such as intractable overactive bladder,neurogenic bladder causing upper tract damage(kidney damage),Detrusor-External Sphicter Dyssenrgia( causing intermittent flow,obstructed stream in Neurological illnesses),chronic prostatic pain,non fibrotic bladder outflow obstruction(prostatic enlargement).
But the most common usage of BOTOX is in irritative bladder symptoms (frequency,nocturia,urgency,urge incontinence not yielding to medicines).The overactive bladder symptoms if doesnot abate with usual anti-cholinergic medications makes the life of the patient miserable. It will have physical problems-leakage causing personal inhygiene, psychological problems-embarrassment and loss of dignity, social problems-social isolation, sexual problems- because of genital skin rashes and foul smell( partner will have repulsion) etc.
The overactive bladder is widely prevalent affecting 50-100 millions of people all around the globe and some of them don’t respond to conventional treatments.These are the people who suffer silently and eventually end up in depression and self esteem.The BOTOX provides a ray of hope in such patients.
Typically 100-300 Units of BOTOX –A toxin is used. Briefly, the BoNT/A dose (200 or 300 units) is reconstituted with saline 0.9% at a total volume of 30 mL. The actual procedure of giving bladder Botox injections is fairly simple. It will take less than 20 minutes, and is minimally invasive. The procedure can be performed under local or general anaesthetic, and will not require an overnight stay in hospital.
A cystoscope – a small tube containing a camera – is passed into the bladder through the urethra so that the surgeon can inspect the inside of the bladder before performing the operation. A very thin needle is then passed through the cystoscope, and Botox is injected into between 20 and 30 different areas of the bladder muscle walls

BOTOX BEING INJECTED IN BLADDER FOR NEUROGENIC BLADDER
The BOTOX helps in alleviation of urological symptoms in 80% of the cases and the effect of BOTOX instillation lasts for 6-14 months.The injection can be repeated at those intervals.The BOTOX injection rarely causes systemic toxicity and rarely causes bladder paralysis needing long term catheterization.
One other area where BOTOX helps is neurogenic voiding dysfunction-either Detrusor Hyperreflexia or Detrusor External Sphincteric Dyssenergia in children with spina bifida/meningocele/myelomeningocele. These voiding dysfunction can gradually destroy the kidneys because of high bladder pressures.This can be brought down with BOTOX and kidney function thus preserved.
Certain novel areas like intractable chronic prostatitis and benign prostatic enlargement especially with detrusor overactivity ; many urologists have started using it with promising results.
The main implication of the BOTOX is that many patients having lower urinary tract symptoms with incontinence,urgency are elderly population with lot of other associated comorbidities like heart ailments.This makes them unsuitable for the conventional surgery if the medical line of treatment fails.In these group of patients BOTOX comes as a boon relieving them of the incontinence as it can be performed under local anaesthesia.
BOTOX although many people have reservations about its usage in urology is here to stay and its acceptance is going to increase because of its simplicity of performance and promising results.

Buccal Mucosal Graft Urethroplasty : A recent case

2010-05-23T06:27:00.000-07:00

A -27- old gentleman came with history of weak stream, straining at micturition.There was no history of obvious trauma or prior urological intervention( like catheterization).He did not have the history of exposure also.There was no evidence of Balanitis Xerotica Obliternas on genital skin and mucosa.
He was evaluated and found to be short segment stricture in the proximal bulbar urethra.
He underwent multiple endoscopic interventions and urethral dilatations.
He needed recurrent dilatations. He was advised option of definitive urethroplasty.

He was taken up for ventral onlay urethroplasty.

Under spinal anesthesia through a midline perineal incision the bulbar urethra is exposed without mobilisation. Methylene Blue dye was injected through the meatus. A bougie was passed through the meatus upto the level of the stricture. Ventral urethrotomy is performed through the strictured urethra into normal proximal bulbar urethra upto 1.5cm. Methylene Blue stained urethral mucosa helps to identify the narrowed lumen of the urethra. A 2 cm wide and 6cm long buccal mucosal graft harvested from the cheek and it was defatted.

The BMG is sutured to the urethral mucosa with continuous sutures of 4/0 vicryl to the ventral urethrotomy throughout. A 14 F silastic Foley catheter was inserted to the bladder. The corpora spongiosa was over closed with continuous sutures of 4/0 vicryl and taking anchoring stitches through the buccal mucosa graft. The wound is closed in layers. The catheter is planned to be removed after 4 weeks.

Angioembolisation in Haemorrhagic cystitis

2010-05-21T08:27:00.000-07:00

a 65 year old man presented to us with frank hematuria of 1 day duration. he was known case of small capacity bladder with hemorrhagic cystitis with no apparent reason.He was operated in 2002 for clam cystoplasty. He was apparently alright for 8 years just to land up in emergency department with gross total hematuria.

He is known case coronary artery disease and hypertension on medication.He was on ecosprin when he came for hematuria.
Immediately ecosprin was stopped.He was supported with irrigation,tranexa and cystoscopy and evacuation followed by alum irrigation.
After this surgery he was fine for 2 days then suddenly he had bout of frank hemturia causing fall of Hb from 13 TO 10 GM% and BP to fall from 130/80 mm Hg to 70/30 mmHg.

He was immediate taken up for cystoscopy and clot evacuation again with institution of proper blood support and plasma expander support.The bladder base region had angry looking globular mass? Rest of the bladder mucosa and the intestinal mucosa was normal.

The clots were removed with resectoscope and cautery and ellicke evacuator.A three way Foleys catheter was introduced wnd alum irrigation was started..The urine effluent was clear.

aFTER THE CLOT EVACUATION WAS DONE BILATERAL ANGIOEMBOLISATION WAS CARRIED OUT SELECTIVELY ON ANTERIOR DIVISION OF INTERNAL ILIAC ARTER USING SELDINGERS TECHNIQUE.The both iliac arteries anterior divison was blocked with gel foam mixture viscous with the contrast,

The process of Angioembolisation of the internal iliac artery --the end result of the embolisation is seen as the disapperance of the terminal branches of the vesical arteries.
The next plan was if the patient bleeds again then re-ileal conduit and extirpation of the diseased bladder at a later point of time.

The urological hemorrhage is an important problem in contemporary urological practice with significant associated morbidity and mortality. furthermore, these emergencies present a number of challenges to clinicians as current practice has evolved due to the increased availability of new imaging techniques and transarterial embolisation (tae). in this review we have explored the epidemiology, etiology and management of both renal and bladder hemorrhage. renal bleeding secondary to accidental or iatrogenic trauma and neoplastic disease requires careful but expeditious assessment and treatment. we have described current conservative, surgical and radiological approaches to the management of this challenging problem. moreover, bladder hemorrhage due to hemorrhagic cystitis, boadder cancer and infection represents a significant problem in current practice. advances in technology have changed the management options and again we have explored the literature in order to determine the optimum treatment approaches.

Post-Papavarine Injection Priapism:Management

2010-05-19T06:33:00.000-07:00

A 35 year old gentleman presented with painful persistent penile erection after the injection of papavarine for penile doppler evaluation .The penile doppler and the intra-corporal injection were given 12 hours before.He had erection lasting for almost 12 hours before he presented to us.

The examination revealed tender turgid erecion with glans also rigid.

He was taken up for immediate intra-corporal aspiration with 21 G scalp vein.About 200 ml dark blood was evacuated followed which red blood started coming.

Then Phenyl Epinephrine (1 ml in 20 ml----500 mcg) was injected and kept for 5 moin.Then the rigidity was seen to subside.

But the tumuscence was still there.

One more dose was given and then the scalp vein was again clamped.Now this time the penis has become totally flaccid

PRIAPISM:

Priapism is erection that persists beyond or unrelated to sexual activity. It is of two types
Low flow-This is because of priapism due to lack of outflow leading to congestion of blood in corpora and subsequent decrease in arterial flow leading to ischemia. In this there is anoxia of smooth muscle component of corpora.
PRIAPISM IS AN EMERGENCY. Any delay in the treatement will result in corporal ischemia and fibrosis. This will lead to permanent erectile dysfunction and penile deformity.
High Flow: This is due to trauma to perineum causing arteriovenous fistula and increased flow. This is not an emergency.
History-Detailed history regarding Intracavernosal Injection of Vasoactive agents, Hematological diseases, substance abuse, perineal trauma should be taken. The duration and any accompanying pain should be inquired. Any past history of priapism should be inquired.
Clinical examination-

Very Important to feel for any Malignant induration (metastases causing priapism), Bruit in perineum (trauma related high flow priapism). These obviously pinpoint to aetiology and help in treatment.
Invstigations:
1) Duplex Doppler Ultrasound-to differentiate between low and high flow priapism. Duplex ultrasound will reveal low flow and constricted cavernosal artery while in high flow the flow will be turbulent indicative of arteriovenous fistula.
2) Cavernosal Blood gas Analysis (Important) Ph< 7.25, pCO2>60,pO2>30 (Low Flow).The arterial blood gas picture is reverse in High Flow variant. This is an important necessary tool because it definitively pinpoints the type of priapism. It involves aspiration of blood from the corpora and sending it to ABG analyser(usually present in ICU)
Management

Low flow variety
1) Hematological disorders-Always hydrate the patient first
2) If Priapism less than 4 hours-Intracavernosal Injection of Phenylephrine bolus 500mcg repeated after 5 minutes. Importantly patient’s vitals should be kept on monitoring.
3) If priapism more than 4 hours-Drain one corpora with 21 G scalp vein with aspiration to remove old anoxic blood and inject a bolus of Phenylephrine ( 1 ml of Phenylephrine with 19 ml Normal saline mixture).The scalp vein should be clamped for 5 minutes. Repeat the procedure if there is no response.
4) Alternatively drain the corpora with 20 G scalp vein passively and let the blood drain out on its own. Initially the drained blood is dark anoxic slowly once the smooth muscle component of the corpora recovers red blood oozes out and that is the end-point of the drainage.

5) No response-------Send to Andrologist for Performance of corpora-glanular shunt (AL GHORAB SHUNT) .This procedure is simple .It can be done under penile block anaesthesia. It involves peroration of the corpora cavernosa through spongiosum (glans).This is followed by dilatation of the fenestration by Hegar´s dilator. The aim is to allow drainage of anoxic cavernosal blood into relatively supple spongiosum. The glans wound is then closed .This procedure is safe and quick.

High flow variety:
Initially conservative treatment like application of pressure packing, ice packing, use of adrenergic agents as written above. If these measures fail then Internal pudental angiography and angioembolisation is the treatment.
Stuttering Priapism:
Many patients, especially children, have a pattern of multiple short episodes over a period of days or several weeks. The priapism is often normal flow and prognosis is generally good and therapy is conservative. If the episode lasts longer and turns painful; then it should be like low flow variety. The long term prevention can be done with Baclofen 40 mg at the bed time.

Detect Prostate Cancer Early to cure Completely

2010-05-18T23:40:00.000-07:00

Andrology Department in Dr Ramayyas Hospital

2010-05-18T05:26:00.000-07:00

We are glad to announce that a full fledged dedicated andrology department in Dr Ramayyas Urology Nephrology Hospital is functional.
We have started doing microsurgical reconstructive surgeries for male infertility and also for varicocele.
These are the facilities available in the hospital:
Semen analysis
Hormone profile measurement
Tran-rectal ultrasound
Testicular biopsy (diagnostic)
Vasography
Colour doppler ultrasound for the testes
Micro-surgical varicocelectomy
Microsurgical vasectomy reversals
Micro-surgical vaso-epididymostomy
Fertility preserving hernia and hydrocele repair
Trans-urethral ejaculatory duct resection
Seminal vesiculoscopy
No-scalpel vasectomy(NSV)
Sperm retrieval-microsurgical/open(Microdissection TESE)
Impotence evaluation and treatment
Medications for potency and pre- mature ejaculation
Bimix injections for potency
Vacuum erection devices/ penile rings
Penile venous ligation surgery
Penile implants
Penile revascularization surgery (post-trauma patients)
Surgery for penile curvatures and Peyronies disease

Urinary Incontinence:a Review

2010-05-17T07:49:00.000-07:00

Stress Urinary Incontinence

1. An involuntary loss of urine during coughing, or physical exertion
2. Evident as leakage of urine on increased abdominal pressure without change in detrusor pressure (VLPP) during filling phase on UDS(SPECIALISED PRESSURE MANOMETRY)

It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners.

Usual cause of stress urinary incontinence
1. Vaginal delivery--multiple vaginal births(unattended deliveries common in ESPECIALLY in villages)
2. Aging
3. Estrogen deficiency(Some woman leak one week before menstrual period.The lowered estrogen levels that particular time may lead to lower muscular pressure around the urethra, increasing chances of leakage. The incidence of stress incontinence increases following menopause, similarly because of lowered estrogen levels)
4. Neurological disease(especially diabetes)
5. In female high-level athletes, effort incontinence occurs in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance

As In India; multiple vaginal births are a common scenario and there is cultural taboo so incontinence is very high in prevalence but majority of household women suffer from it silently.Many of them avoid mingling in social occasions for fear of leakage preferring to remain aloof.The urine leakage is equally annoying to their sex partners which may severely affect sex life and adversely affect married life.There are certain myths in society about stress urinary leakage:
1. Urinary incontinence/prolapse is a natural part of aging
2. Nothing can be done about it
3. Surgery is the only solution(phobia for doctors;thinking that they will invariably suggest surgery for the disease)

Prevalence:
Reported prevalence rates range from 4.5% to 53%
Our Hopsital Statistics shows:
1. 50 Patients of stress/mixed incontinence / 6 months
2. 10 Undergo UDS/ 6months
3. 3-4 Undergo surgical intervention

Can we do something to remove doctor phobia especially in Indian society?
Can Nurse led continence service of any use?

A study was conducted by Matharu et al in 2004 where women aged ≥40 yrs with LUTS (n= 2421) were randomly allocated to a nurse-led continence service.Out of them , 450 underwent urodynamic study.The results showed women with OAB, 79.1% were correctly allocated anticholinergics & 64.8% were allocated pelvic floor training protocol(PFT).Of all women with urodynamic SUI, 88.8% were allocated PFT.This shows that nurse led continence service fairly treat women and this type of service can be initiated by Government of India to avoid urine leakage misery.

Management of tress urinary incontinence:
Continence and micturition involve a balance between urethral closure and detrusor muscle activity. Urethral pressure normally exceeds bladder pressure, resulting in urine remaining in the bladder. The proximal urethra and bladder are both within the pelvis. Intraabdominal pressure increases (from coughing and sneezing) are transmitted to both urethra and bladder equally, leaving the pressure differential unchanged, resulting in continence. Normal voiding is the result of changes in both of these pressure factors:urethral pressure falls and bladder pressure rises. SUI is due essentially to insufficient strength of the pelvic floor muscles. It is the loss of small amounts of urine associated with coughing, laughing, sneezing, exercising or other movements that increase intra-abdominal pressure and thus increase pressure on the bladder. The urethra is supported by fascia of the pelvic floor. If this support is insufficient, the urethra can move downward at times of increased abdominal pressure, allowing urine to pass.
So the basic aim of the treatment is Aim: To improve urethral resistance.These are the conservative measures:

1.Weight loss
A study published in The New England Journal of Medicine on January 29, 2009, demonstrated that weight loss in overweight women reduced stress incontinence. The study included women with a Body Mass Index (BMI) over 25 and at least 10 episodes of urinary incontinence per week. The results demonstrated that with exercise and restricted diet they had a 70% or greater reduction in overall incontinence episodes.So weigth loss should be the first thing a woman ahould follow for reduction in incontinence.
2. Absorbent products
Absorbent products include, undergarments, protective underwear, briefs, diapers and underpads.There are some assist devices used like vaginal pessaries,femsoft catheter as physical barrier for prevention of urinary leakage.
4. Exercises
One of the most common treatment recommendations includes exercising the muscles of the pelvis. Kegel exercises to strengthen or retrain pelvic floor muscles and sphincter muscles can reduce stress leakage.

Role of pelvic floor training:
The Cochrane Incontinence Group Specialized Trials Register included One arm comprised PFT, the other either no treatment, placebo, sham treatment. A total 13 trials involving 714 women were included.They concluded that PFT be included in first-line conservative management programs.Basically suffering woman should Identify the pubococcygeus muscle first with the help of urologist and then Exercise the muscle (10 s contraction followed by 10 s relaxation) 30 to 80 times /day.This Increases muscle support of the pelvic viscera &increased closing force on the urethra and the benefits may be seen in 2 to 6 weeks.
An alternative or adjunct to PME is exercises the pelvic muscles by holding small weights inside the vagina for up to 15 minutes bid.Successiely the weights can be increased I ncreasing the capacity of the pubococcygeus muscle contraction.Success rate up to 70% to 80%. A recent Cochrane Review shows no advantage to combining PFT with biofeedback over the use of well-done PFT alone.Atleast 3 months of pelvic floor exercises are necessary.
Biofeedback:
Biofeedback uses measuring devices to help the patient become aware of his or her body's functioning. By using electronic devices or diaries to track when the bladder and urethral muscles contract, the patient can gain control over these muscles. Biofeedback can be used with pelvic muscle exercises

RESULTS OF PELVIC FLOOR TRAINING:
There was a trial
1. 76 women underwent a 3-month exercise program & followed for 1 year.
2. 30% of subjects were cured &17% were improved.
3. Subjects with severe incontinence did not benefit from the therapy

Medications
Medications can reduce many types of leakage. Drugs with a-adrenergic activity to increase bladder outlet resistance.For Example ..phenylpropanolamine 25-75 mg bid &imipramine10-25 mg qd-tid.These medicines have been taken off from the U.S. market because of concerns about hemorrhagic strokes in young women.A new nedicine has been tried in SUI:duloxetene :called drug which kills three birds in one stone. It is Combined serotonin and nor-epinephrine re-uptake inhibitor.Its actions are :
o Increases tone of external urethral sphincter
o In an integrated analysis of 4 randomised controlled trials, it significantly decreased incontinence episode frequency by 51.5%
A study by Drutz et al revealed In a subgroup of women with severe SUI awaiting surgery, duloxetine was found to be effective.Incontinence decreased by 46% or their Incontinence Quality of Life (I-QOL) score improved by 6.3 points.

Vaginal oestrogens:
Vaginal oestrogens are used in SUI especially in aging population.The basis behind is
• Common embryonic origin of bladder urethra & vagina
• High concentration of estrogen receptors in pelvic tissues
• General collagen deficiency state (falconer et al., 1994)
• Urethral coaptation affected by loss of estrogen

The oestrogen cream can improve the mucosal integrity and suppleness of the urethra and the vagina thereby take care of the urethral coaptation.These medicines can produce harmful side effects if used for long periods. There is an increased risk of cancers of the breast and endometrium (lining of the uterus). A patient should talk to a doctor about the risks and benefits of long-term use of medications.
When should doctor send the patient for surgery?(Vague indicators)
1. Severe SUI(≥ 2 PADS /DAY)
2. Duration of symptoms> 5 years
3. VLPP≤80 cm H2O-Urdynamic parameters
Apart from that:
1. Pt with significant associated prolapse that may be corrected at the same time
2. High levels of physical stress owing to lifestyle or occupation-models,athletes,stage performers
Summary:
a) SUI needs to be treated with conservative measures initially: simple, inexpensive and without complications
b) No need of UDS prior to conservative measures
c) Duloxetine helpful in noncompliant pt.

Surgical Management of Stress Urinary Incontinence
Marshall Marchetti Krantz (MMK)
This procedure requires an abdominal incision. The bladder neck and urethra are separated from the back surface of the pubic bone. Sutures are placed on either side of the urethra and bladder neck, which are elevated to a higher position. The free ends of the stitches are anchored to surrounding cartilage and pubic bone.
Burch Colposuspension
This vaginal suspension procedure often is performed when the abdomen is open for another purpose, such as abdominal hysterectomy. The bladder neck and urethra are separated from the back surface of the pubic bone. The bladder neck then is elevated by lateral sutures that pass through the vagina and pubic ligaments.

Needle Suspension
Several needle suspension procedures have been developed, each named after its creator (e.g., Stamey, Raz, Gittes); however, the basic technique is the same. Essentially, sutures are placed through the pubic skin or a vaginal incision into the anchoring tissues on each side of the bladder neck and tied to the fibrous tissue or pubic bone.
Sling Procedures
Patients with severe stress incontinence and intrinsic sphincter deficiency may be candidates for a sling procedure. The goal of this treatment is to create sufficient urethral compression to achieve bladder control.
There are two techniques:
percutaneous, which requires a small abdominal incision, and
transvaginal, which is performed through the vagina.
Percutaneous slings
The pubovaginal sling is made of a strip of tissue from the patient's abdominal fascia (fibrous tissue). A synthetic sling may be used, but urethral tissue erosion commonly occurs.
An incision is made above the pubic bone, and a strip of abdominal fascia (the sling) is removed. Another incision is made in the vaginal wall, through which the sling is grasped and adjusted around the bladder neck. The sling is secured by two sutures loosely tied to each other above the pubic bone incision, providing a hammock to support the bladder neck.
Possible complications include accidental bladder injury, infection, and prolonged urinary retention, which may require chronic intermittent self-catheterization.
Transvaginal slings

No abdominal incision is required and a small incision is made in the vaginal wall. The permanenet tape is introduced via the vagina .The trocars are used to introduce the tape are removed through small incisions at both the sides of the inner thighs.

Overactive bladder:
• Overactive bladder (OAB) is a syndrome characterized by
 Urgency
 With or without urge incontinence
 Usually accompanied by frequency and nocturia
Prevalence:
• Worldwide it is known to affect 50-100 million people
• OAB affects approximately 16%-22% of adult population.

• The Prevalence increases with advancing age.

National Overactive Bladder Evaluation (NOBLE) Study: Similar Prevalence Among Men and Women
Effects of overactive bladder:
1)Physical Problems:
 Limitation of physical activities
 Discomfort due to dampness
 Unpleasant odour
 Skin rashes/ ulcers
 Confinement in nursing homes
 Insomnia
 Falls

2)Psychological problems:
 Loss of independence — feels tied to home
 Fear of embarrassment
 Loss of dignity & self esteem
 Affects career
 Depression
 Suicide

3)Social problems:
 Reduction in social interaction/ increased social isolation
 Alteration of travel plans (e.g. plan around availability of toilets)
 Cessation of some hobbies
4) sexual problems:
 Avoidance of sexual contact
Basic evaluation for patient of urgency
To be done in all patients
 History & micturition diary
 Physical examination
 Laboratory tests
Supplementary assessments.
 BUN, Serum creatinine.
 Serum Glucose.
 Urine cytology and AFB.
• Specialized tests must be tailored according to the questions that need to be answered:
 Urodynamic Tests: in medication failure,prior to invasive therapy
 Endoscopic tests:hematuria,sterile pyuria
Management of overactive bladder:
• Non-pharmacologic methods:
Bladder training/PFT: Pelvic Floor Muscle Training:
• Drawing in” or “lifting up” of peri-anal musculature with minimal contractions of abdomen, thigh and buttocks
• Contractions to be sustained for at least 10 seconds and done for 30-80 times/day for at least 8 weeks (Ferguson et al;1990)
• Standards for assessment of change in pelvic function not yet established

• Pharmacotherapy

Various drugs used in overactive bladder

• Botox:
Botox :A toxin –dose:300 U,
Injected intravesically(over 25-30 sites)
Causes afferent nerve denervation
Injection repeated every 6 monthly

• Neuromodulation:
 S3 afferent nerve stimulation inhibits detrusor activity at the level of the sacral spinal cord
 Sacral nerve stimulation therapy consists of two parts
 An initial percutaneous nerve evaluation (PNE)
 Followed by surgical implantation of a permanent electrode lead and pulse generator.

• Surgery:Augmentation cystoplasty:
 Patch of detubularized intestine used to augment bladder
 Complications (30-50%)
o Intestinal obstruction
o Need of CIC
o Calculus
o Metabolic complications
o Malignancy

Percutaneous Nephrostomy:Life saving measure in obstructed kidneys

2010-05-17T00:34:00.000-07:00

A 50 year old lady came to us with history having tretaed for Carcinoma Cervix stage 3 B.She had recieved 4 fractions of EBRT outside.

She had history of pain in right flank and fever since 2 days.Her investigation revealed anemia,polymorphonucelocystosis,raised creatinine 11.4mg%

She was taken up for emergency PCN(percutanoeus nephrostomy).

The both pelvicalyceal systems were punctured with 20 G cheeba needle with ultrasound guidance.Then dyestudy was performed.
After the pelvicalyceal delineation,both the systems were punctured with 18 G PCN needle in posterio-inferior calyx.The guidewire was then placed and the tract was subsequently dilated till 16 fr.At the end of the procedure 14 Fr Malecots was placed in both systems.

There was hydronephrotic drip on both sides.She is supplemented with fluids and strict watch has been kept on her Electrolytes and ABG parameters to prevent post-obstructive diuresis and its complications.

Once the creatinine comes up she will be fit for stenting as the kink in ureter due to malignancy will disappear and she will be a good candidate for chemotherapy.

The facilities for emergency PCN are necessary at every Hospital and all the urologists should be well trained for the same as it can obviate the need for hemodialysis in such situations.It can be life saving measure and does not take more than 30 minutes.

Renal cel Carcinoma:Review

2010-05-15T01:51:00.000-07:00

The kidneys are dark-red, bean-shaped organs. There is a cavity attached to its concave side which drains into a tube which extends all the way to bladder.
Each Kidney is enclosed in a transparent membrane called the renal capsule which helps to protect them against infections and trauma. The kidney is divided into two main areas a light outer area called the renal cortex, and a darker inner area called the renal medulla. Within the medulla there are 8 or more cone-shaped sections known as renal pyramids. The areas between the pyramids are called renal columns.

Anatomy of the kidney:

What is renal cell carcinoma:
Renal cell carcinoma is the most common type of kidney cancer in adults. It occurs most often in men ages 50 - 70.
The exact cause is unknown.
Risk factors include:
• Dialysis treatment
• Family history of the disease/Genetics
• Horseshoe kidney
• Von Hippel-Lindau disease (a hereditary disease that affects the capillaries of the brain, eyes, and other body parts)
Renal cell carcimoma (RCC) is the third most common genitourinary cancer after prostate and bladder. Majority (80% to 85%) of kidney tumors are malignant. It is the most lethal malignancy of all urological cancers.
Unique characteristics of RCC
 lack of early warning signs,
 diverse clinical manifestations,
 resistance to radiation and chemotherapy, and
 immunogenic nature and spontaneous regressions.

What are the symptoms:
Now a days many renal cell carcinomas are detected incidentally during routine ultrasound examinations.
Otherwise the symptoms of renal cell carcinoma are:
Pain in flank (due to capsular distension)
Hematuria
Varicocele
Back pain
Systemic symptoms-fever,weight loss,loss of apettite
Anemia
Some times it can cause paraneoplastic symptoms like-hypertension,polycythemia

Diagnosis
Tests include:
• Abdominal CT scan: to see the size,extent and spread of the tumor

• Blood chemistry :Renal function tests
• Ultrasound of the abdomen and kidney : this is screening test
• Complete blood count (CBC): for anemia or polycythemia
• Intravenous pyelogram (IVP):Now –a days not routinely performed
• Liver function tests: staging work up
• Renal arteriography : sometimes necessary if Inferior Vena Cava spread then angioembolisation can downstage the tumor and make it less vascular and easier to operate.
• Urinalysis and urine cytology : sometimes Transitional Cell Carcinoma can mimick Renal cell Carcinoma which has different management after the initial surgery.
The following tests may be performed to see if the cancer has spread:
• Chest CT scan
• Bone scan
• MRI: especially if Inferior Vena Cava spread is suspected
• PET scan

Staging

Stage I
is an early stage of kidney cancer. The tumor measures up 7 centimeters

Stage II
is also an early stage of kidney cancer, but the tumor measures more 7 cm in size and the cancer is confined to the kidney.
Stage III is one of the following:
• The tumour has spread to adjacent renal vein or Inferior vena cava or lymph nodes
Stage IV is one of the following:
• The tumor extends beyond the fibrous tissue that surrounds the kidney(Gerotas Fascia);
• Cancer has distant spread

Treatment
Radical nephrectomy remains the treatment of choice for organ confined renal cell carcinoma.
The prototypical radical nephrectomy involves removal of the cancerous kidney outside the Gerotas fascia along with the adrenal and lymphadenectomy from aortic bifurcation to crus of diaphragm.(although there are a lot controversies about the lymphadenectomy)

This can be done by Laparoscopy which uses 4 -5 ports inside the abdomen and the organ is extracted with small lower abdominal incision.Sometimes morcellation can be used to avoid the incision.
In small tumour(less than 4 cm) especially in solitary kidney or multiple tumours both the kidney a partial removal of the kidney encompassing tumour with the 5-10 mm of the normal renal parenchyma is done either by open of laparoscopic method.
When the tumor has spread to Inferior vena cava- then extensive surgery with or without cardiac bypass is needed for complete extirpation of the malignancy.
In case of unfit patients or with multiple comorbidities or multiple tumours cryo-ablation of Radio-frequency ablation can be resorted to.

Laparoscopic Cryo-ablation in process
Advanced Renal Cell Carcinoma:

RCC diagnosed early can be managed with nephron sparing or radical nephrectomy with excellent 5 year survival and prognosis. The problematic cases are those presenting as advanced disease at the initial presentation. The advanced disease includes: T4 N0 M0, or any T, any N, M1. These cases are associated with poor survival and limited treatment options.
Options for chemotherapy and endocrine-based approaches are limited, and no hormonal or chemotherapeutic regimen is accepted as a standard of care. Therefore, various biologic therapies have been evaluated. New agents, such as sorafenib and sunitinib, having anti-angiogenic effects through targeting multiple receptor kinases, and have been investigated in patients failing immunotherapy.
Role of surgery
Palliative nephrectomy should be considered in patients with metastatic disease for alleviation of symptoms such as pain, hemorrhage, malaise. Several randomized studies are now showing improved overall survival in patients presenting with metastatic kidney cancer who have nephrectomy followed by either interferon or IL-2. If the patient has good physiological status, then nephrectomy should be performed prior to immunotherapy. There are anecdotal reports documenting regression of metastatic renal cell carcinoma after removal of the primary tumor but adjuvant nephrectomy is not recommended for inducing spontaneous regression; rather, it is performed to decrease symptoms or to decrease tumor burden for subsequent therapy in carefully controlled environments.

IMMUNOTHERAPY
The immune modulators, such as interferon, interleukins (IL-2, have been tried.
A : Interferons -The interferons are natural glycoproteins with antiviral, anti-proliferative, and immuno-modulatory properties. They have a direct anti-proliferative effect on renal tumor cells in vitro, stimulate host mononuclear cells, and enhance expression of major histocompatibility complex molecules.
Interferon-alpha, which is derived from leukocytes, has an objective response rate of approximately 15% (range 0-29%).
Interlukin -IL-2 is a T-cell growth factor and activator of T cells and natural killer cells. It hampers tumor growth by activating lymphoid cells in vivo without directly affecting tumor proliferation. It can be administered as high dose and low dose regimen.
A high-dose regimen (600,000-720,000 IU/kg q8h for a maximum of 14 doses) results in a 19% response rate with 5% complete responses. The majority of responses to IL-2 were durable, with median response duration of 20 months. Eighty percent of patients who responded completely to therapy with IL-2 were alive at 10 years. Most patients responded after the first cycle, and those who did not respond after the second cycle did not respond to any further treatment. Therefore, the current recommendation is to continue treatment with high-dose IL-2 to best response (up to 6 cycles) or until toxic effects become intolerable. Treatment should be discontinued after 2 cycles if the patient has had no regression.
Combinations of IL-2 and interferon or other chemotherapeutic agents such as 5-FU have not been shown to be more effective than high-dose IL-2 alone
Toxicity is dose dependent. Most common dose dependant toxicity is hypotension requiring vasopressors. Also malaise, diarrhea, pyrexia, and rashes are commonly reported toxicities.
Approved for treatment of patients with metastatic RCC.
Durability of response: Approximately 60% of CRs remain disease free at > 10 yrs follow-up
Biological Therapy:
Sunitinib (Sutent) Sunitinib is another multi-kinase inhibitor approved by the FDA in January 2006 for the treatment of metastatic kidney cancer that has progressed after a trial of immunotherapy. The approval was based on the high response rate (40% partial responses) and a median time to progression of 8.7 months and an overall survival of 16.4 months. The receptor tyrosine kinases inhibited by sunitinib include VEGFR 1-3 and PDGFR.
Major toxicities (grade II or higher) include fatigue (38%), diarrhea (24%), nausea (19%), dyspepsia (16%), stomatitis (19%), and decline in cardiac ejection fraction (11%).
A recent phase 3 study evaluating sunitinib in the first-line setting, compared against IFN-, in patients with metastatic RCC demonstrated significant improvement in PFS and response rates compared against the control arm. These results are considered to be preliminary, and longer-term follow-up is necessary for conclusive results.

ESWL:Non-Invasive treatment for stone fragmentaion

2010-05-14T00:31:00.000-07:00

We had one 35 year old gentleman who presented to us with the bilateral renal calculi 1-1.5 cm with normal functioning kidneys.He was prestented in a view if the stones donot get fragmented with ESWL then after 4 weeks ,Retrograde Intra Renal Suregry (RIRS) can be done.
During the procedure there was good fragmentation.He is planned for review after 4 weeks and imaging at the same time.

Until 20 years ago, open surgery was necessary to remove a stone. The surgery required a recovery time of 4 to 6 weeks. Today, treatment for these stones is greatly improved, and many options do not require major open surgery and can be performed in an outpatient setting.
Extracorporeal Shock Wave Lithotripsy
ESWL or extracorporeal shock wave lithotripsy has revolutionized the treatment of renal stones. Kidney stones less than or equal to 1.5 cm in size in the kidney or upper ureter are best treated with ESWL.
Usually, this is an outpatient type of procedure using IV sedation or full anesthesia.

Treatment time runs from 1 to 2 hours. The stone is usually visualized with fluoroscopy and once centered for treatment, a shock wave is generated that penetrates the body and impacts upon the stone. After usually 3000 shocks are given, the stone gradually pulverizes, and the fragments are passed spontaneously over the next several days to weeks (It may sometimes take upto 3 months to pass all the fragments).

Complications of this procedure bleeding which is self resolving, infection so peri-procedure cover of antibiotics is essential. The third potential complication is sometimes the stone breaks and the gravels line up along the lower ureter making it necessary for the patient to undergo secondary/auxialiary procedure- Ureteroscopic clearance.
As with any procedure; pre-operative urine culture should be sterile and the patient should be off from the anti-platelet agents atleast for the 7 days for the safety otherwise large hematomas not only in kidneys but also in liver and adjacent organs are reported.

Laparoscopic Cholecystectomy: Brief overview

2010-05-13T00:45:00.000-07:00

Gall Bladder is a Pear shaped accessory digestive organ situated just beneath the liver.It is a small organ that aids digestion and stores bile produced by the liver(It can store uptom 50 ml of bile). In humans the loss of the gallbladder is not fatal... When the concentration of cholesterol or fats increases in the bile juice it precipitates as stone in the Gall Bladder. It can occur in all age groups and in both males and females, though more commonly in females. The five F’s of Gall Bladder stone diseases are “A Fat, Flatulent, Fair, Female of Forty is more likely to have gall stones”.

Laparoscopic cholecystectomy requires 3-4 small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5-10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity(usually through the umbilical opening). The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.
To begin the operation, the patient is anesthetized and placed in the supine position on the operating table. A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle(closed technique) or Hasson technique(open technique) the abdominal cavity is entered. The surgeon insufflates the abdominal cavity with carbon dioxide to create a working space.. Additional ports are placed inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (the area bound by the cystic artery, cystic duct, and common hepatic duct). The triangle is gently dissected and then the cystic duct and the cystic artery are identified, clipped with tiny clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases can be done in about an hour.

Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS".

Androgen Deficiency in Aging Male and huge prostatomegaly: Dilemma of management

2010-05-12T07:31:00.000-07:00

A patient presented to us in Ramayyas Urology and Nephrology Hospital with complaints of erectile dysfunction and lower urinary tract symptoms. As per the detailed history there was history of decrease libido, difficulty in maintaining the erection and frequent mood alterations also.

On examination the patient had bilateral hydrocele and normal testes(size and texture).The prostate showed Grade 4 enlargement .
The investigation revealed huge prostatomegaly (187 gms) and Sr PSA 11.81 NG/ML. His testosterone was subnormal 1.63 ng/ml( below the reference range).So the patient had grade 4 enlargement of prostate with high PSA and ADAMS(Androgen Deficiency of Aging Male )

Having tried Vacuum erection device which he felt was not suitable for his use and having not satisfied with the effect of PDE-5 inhibitors ;he was given option of testosterone supplementation.But taking into consideration high PSA there was chances of occult carcinoma which needed to be excluded.
The prostatic enlargement of 187 gm and high PSA with uroflowmetry showing Maximum Flow rate of 12 ml/sec also pointed out to benign prostatic hyperplasia which would need treatment (medically-Dutasteride would have complicated the erectile dysfunction and alpha blocker - there was chance of retrograde ejaculation).The surgical treatment was deemed to be optimum.
The all options were discussed with the patient.Finally a decision was made to go for PROSTATE BIOPSY(A 14 CORE BIOPSY), bladder neck sparing laser evaporation of the lateral lobe(pt had bilobar prostatomegaly-the right lobe was predominantly enlarged that was removed.This was done with two views: trying to preserve anterograde ejaculation and prevention further complication because of prostate enlargement after testosterone supplementation) and bilateral hydrocelectomy.
The prostatic biopsy report was negative for malignancy.He was started on Viagra( continuous therapy to take care of endothelial dysfunction rather as on when needed basis and testosterone supplementation once biopsy is negative) and androgen replacement therapy with Zandrova(testosterone cream 5 gm sachet locally) daily on shoulder after bath .

From andrological point of view he will be under complete follow-up with regular PSA and evaluation of improvement of erectile dysfunction.

Laparoscopic Hernia Repair: A brief information

2010-05-12T07:20:00.000-07:00

Laparoscopic Inguinal Hernia Repair
WHAT IS A HERNIA?
• An abdominal hernia is an abnormal protrusion of an abdominal organ through an abnormal defect in the wall of the abdominal wall.. This can allow a loop of intestine or abdominal tissue to push into the sac. The hernia can cause severe pain and other potentially serious problems like intestinal obstruction/gangrene that could require emergency surgery.

1:abdominal wall;2:intestines,3:hernia
• Both men and women can get a hernia.
• You may be born with a hernia (congenital) or develop one over time (acquired).
• A hernia does not get better over time, nor will it go away by itself (only surgical cure is there there is no role of medications).
What are the symptoms?
• The common areas where hernias occur are in the groin (inguinal), umbilicus (umbilical), and the site of a previous operation (incisional).

• You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, strain during urination or bowel movements, or during prolonged standing or sitting. The hernia usually protrudes during strenuous activity and settles back in abdomen during rest. But sometimes it may not go back(persistent swelling).
• The patient may have dull ache or sharp shooting pain.
• Severe, continuous pain, redness, and tenderness are signs that the hernia may be entrapped or strangulated. This is a sign of emergency .
WHAT CAUSES A HERNIA?
The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, aging, injury, an old incision or a weakness present from birth(congenital hernia).

Anyone can develop a hernia at any age. Most hernias in children are congenital. In adults, a natural weakness or strain from heavy lifting(sportsmen), persistent coughing(ASTHMA/COPD patients), constipation or difficulty in urination(prostatic enlargement ) can precipitate the hernia.
WHAT ARE THE ADVANTAGES OF LAPAROSCOPIC HERNIA REPAIR?
Laparoscopic Hernia Repair is a technique which covers the defect in the parietes using key holes, telescopes and a mesh(prolene mesh/biodegradable mesh). If may offer a quicker return to work and normal activities with a decreased pain for some patients.
ARE YOU FIT FOR LAPAROSCOPIC HERNIA REPAIR?
As the laparoscopy involves insufflations of carbon dioxide gas in abdomen and general anaesthesia ; general fitness is must.Those patients who are not candidates for the laparoscpy can be offered open repair under local inguinal block or spinal/epidural anaesthesia.
Procedure prior to Laparoscopy:

• After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
• Drugs such as antiplatelet agents will need to be stopped temporarily for several days to a week prior to surgery( with the consultation with In-house physician).
• You may be administered enema in night time before the day of the surgery.
HOW IS THE PROCEDURE PERFORMED?
I. The open approach is done from the outside with 5-7 cm incision in the groin. The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect. The surgeon may choose to use a small piece of surgical mesh to repair the defect or hole as shown in figure(Lichensteins tension free hernia repair).

II. The laparoscopic hernia repair. In this approach, a laparoscope (a tiny telescope) connected to a special camera is inserted through a cannula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen.
Other tubes are inserted which allow your surgeon to work "inside." Three or four small incisions are usually necessary. The hernia is repaired from behind the abdominal wall. A small piece of surgical mesh is placed over the hernia defect. This operation is usually performed with general anesthesia

WHAT HAPPENS IF THE OPERATION CANNOT BE COMPLETED BY THE LAPAROSCOPY?
In a small number of patients the laparoscopic method cannot be performed. The factors which may cause difficulty in progress are obesity,presence of scar tissue because of previous surgeries,difficulty in dissection because of incarcerated bowels etc..
When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment.
WHAT SHOULD I EXPECT AFTER SURGERY?
• Following the operation, you will be transferred to the recovery room where you will be monitored for 1-2 hours until you are fully awake.
• You will be transferred to your ward in the evening and allowed sips of fluids in the same day usually.The next day usually the normal diet is started.
• With laparoscopic hernia repair, you will probably be able to get back to your normal activities within 3-4 days. These activities include showering, driving, lifting, working and sexual intercourse.
WHAT COMPLICATIONS CAN OCCUR?
• Few complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair.
• There is a slight risk of injury adjacent organs like urinary bladder, the intestines, blood vessels, nerves.
• Difficulty urinating after surgery is not unusual and may require a catheter into the urinary bladder for as long as one week(especially in patients with prostatic enlargement; we usually do both prostate surgery and hernia repair simultaneously in cases where the prostate is the precipitating factor) .
• Recurrence can occur.(Although with the mesh repair it is less common still it is a rare possibility).
WHEN TO CALL AN EMERGENCY

• Persistent fever over 101 degrees F (39 C)
• Bleeding/Local groin swelling
• Persistent Pain/nausea or vomiting
• Inability to urinate
• Pus discharge from any incision/Redness surrounding any of your incisions that is worsening or getting bigger
• Abdominal distension

Angiokeratoma of the scrotum:Associated with Varicocele

2010-05-11T00:33:00.001-07:00

A 28 year old gentleman presented to us with recurrent bleeding from left hemiscrotum.
He gave no history of trauma. He was married with 2 children and had undergone varicocelectomy surgery 10 years back .
On examination he had grade 3 varicocele on left side and grade 1 varicocele on right side .He had 2-5 mm dark red coloured papules on his left hemiscrotal skin.The dermatologist diagnosed it as Fordyces spots.

In this case we assumed varicocele to be a precipitating factor as Fordyces spots were concentrated on only left hemiscrotum and the varicocele was also Grade 3 severity on left hemiscrotum.

He was taken up for bilateral microsurgical varicocelectomy and will be referred to the dermatologist for probable Laser therapy (CO2).

stricture urethra: a review

2010-05-08T00:10:00.000-07:00

Urethral stricture is an abnormal narrowing of the urethra (the tube that releases urine from the body).

Causes, incidence, and risk factors
The most common cause of anterior urethral stricture is infections.Sexually transmitted diseases can cause infection of the urethral glands(for ex.Bulbo-urethral glands) and resultant inflammation and fibrosis of the region
Other common causes are Balanitis Xerotica Obliterans/lichen sclerosis which can lead to stricture of the whole urethra(pan urethral stricture).This disease usually involves the glans,meatus and the penile pendular urethra.Usually shrunken atrophic glans with meatal narrowing with whitish patches are found on the glans The involvement due to Lichen Sclerosis can be more proximal on the penile skin and pendulous urethra, which is more common than previously thought. Although penile skin may appear normal, microscopic involvement may be present. Moreover it is known that endoscopic manipulation of meatus involved with Lichen Sclerosis also has a potential of disseminating the disease into proximal urethra causing pan-urethral stricture
The trauma either direct because saddle injury or pelvic trauma incurred during the road traffic accidents can cause anterior and posterior urethral injuries and stricture respectively.
The instrumentation (traumatic or repeated) can also lead to trauma. The carcinoma bladder patients who undergo repeated intervention are more prone. Also prostatic enlargement patients who undergo endoscopic prostatectomies are also prone for stricture especially if the gland size is big because the dwelling time of the instruments inside body will be higher in such cases.This will also make urethra more prone for instrumentation leading to stricture.

Symptoms

1)dysuria, weak interrupted stream,urgency,urge incontinence,frequency
2)Recurrent Urinary Tract Infections
3)Hematuria
4)Retention of the urine
5)Urinary incontinence
6)Renal function deterioration

Signs and Tests
A physical examination may reveal the following:
1) Hardness (induration) on the under surface of the penis
2) Whitish Patches on glans,meatal narrowing,shrinkage and atrophy of the glans indicative of Balanitis Xerotica Obliterans
3) Sometimes urethrocutaneous fistula can be found
4) Evidence of pelvic fracture/scars of previous Supra Pubic Catheter placement can also be found.
•
Sometimes the exam reveals no abnormalities:
Tests include the following:
1) Urinary flow rate
2) Post-void residual (PVR) measurement
3) Urinalysis /Urine culture
4) Tests for chlamydia and gonorrhea
5) A retrograde urethrogram to confirm diagnosis

6) Urethroscopy

Treatment
Placement of a suprapubic catheter , which allows the bladder to drain through the abdomen, may be necessary to alleviate acute problems such as urinary retention and infection especially after trauma .

Surgical options vary depending on the location and length of the stricture.

Visual internal urethrotomy may be all that is needed for small stricture. A urethral catheter is left in place after the procedure for anywhere from 3 -10 days .This duration varies from surgeon to surgeon But everybody would agree on principle that prolonged catheterization doesnot prevent the chance of urethral stricture recurrence

An open urethroplasty may be performed for longer stricture by removing the diseased portion or replacing it with other tissue. The results vary depending on the size and location of stricture, the number of prior therapies, and the experience of the surgeon.

Buccal Mucosal Graft Interposition in one case of anterior urethral stricture

In some patients of failed urethroplasties or where the patient is not a good candidate for surgery or even in primary cases stenting is a worthwhile option.The stent is made up of Nickel Titanium Alloy (Memokath 044) and has only a few side effects.The stent is inserted in urethra with the telescope and then expanded with the warm saline irrigation.It expand from 24 to 44 CH.The stent is available from 3 to 7 cms in length.This stent equally easy to remove.

Photograph of the urethral stent placed in long segment urethral stricture

There are no drug treatments currently available for this disease. If all else fails, a urinary diversion -- appendicovesicostomy (Mitrofanoff procedure) -- may be performed to allow the patient to perform self-catheterization of the bladder through the abdominal wall.

spontaneous urinoma with no apparent aetiology in a young girl mimicking a retroperitoneal mass

2010-05-01T22:01:00.000-07:00

A 21 year old patient came to us with history of having been operated outside for ? twisted ovarian cyst.

Pre-operative ultrasound (Before first surgery) showing cystic mass

The laparoscopy was abandoned because contrary to their expectations they found retroperitoneal mass on the right side of the retroperitoneum.
She came to us with a post-operative contrast enhanced CT Scan which revealed urinoma near middle of the right ureter and diffuse ascites. The urinoma was encapsulated in thick capsule (? Chronic process).

On clinical examination she was looking ill and frail. She had loose motions(? Pelvic collection induced).
Her vitals though were maintained except for tachycardia.She had normal hematological and biochemical parameters. Her abdomen was mildly distended with urinary leakage through one of the ports.
She was taken up for Retrograde Pyelography which showed mid-ureteric disruption and dye leaking into a diffuse cavity.The patient was made prone for percutaneous nephrostomy drainage.
Right Percutaneous Drainage was performed through a midcalyceal approach for possible antegrade stenting sometimes in future.
She started draining around 100 ml of urine per hour through the nephrostomy and her leakage of urine through the port and the abdominal distension subsided.Her loose motions also subsided
The very next day she started looking fresh and was back to her normal routine.
She is planned to undergo an evaluation after a period of 6 weeks hoping that till that time the urinoma would subside and the inflammatory reaction would also subside.Then a definitive plan for ureteric reconstruction will be taken up.
This is a rare case of spontaneous urinoma at level of mid-ureter with no apparent aetiology clinically,history and imaging wise.
Having searched the English Literature the urinoma spontaneous in this location was found to be very rare --due to abdominal aortic aneurysm or retroperitoneal fibrosis.In this case both the factors were not seen on CT scan.The possibility of tuberculous lymphadenopathy involving the ureter causing ischemic necrosis of that particular segment leading to spontaneous urinoma is being kept in mind.
She will be investigated for quantiferon TB TEST in the interim .With all said and done probably exploration after 6 weeks and biopsy of the region only might give a definitive clue.

Conservative management of colo-vesical fistula

2010-04-28T01:50:00.000-07:00

A 55 year old lady presented with history of pneumaturia and occasional passage of fecal matter per urethra since 8 days.She was a known case of carcinoma endometrium operated 18 years back with Total Abdominal Hysterectomy followed by chemotherapy and radiotherapy.She was asymptomatic for 10 years then she started leaking ? fecal matter per urethra.She was taken up for endoscopic intervention after which the fecal leakage stopped. She is a known case of diabetic-fairly controlled,hypertension on medications.She was investigated for cystoscopy(diagnostic) which revealed a fistula 2 cm away from the left ureteric orifice cranially and laterally.The fistulogram showed leakage of the contrast into the sigmoid colon. She was given option of open repair of colo-vesical fistula but she preferred an endoscopic approach over open repair.The patient was explained the chances of success and failure and then was taken up for endoscopic repair. She was kept on liquid diet before the planned surgery and also given Peglec for bowel preparation. On the day of surgery , the prophylactic antibiotics were administered and the cystoscopy was started. The fistula was identified in the same position.It was cauterised on all sides with ball electrode with resectoscope instrument. After cauterising the ureteric orifices were cannulated with ureteric catheters and the cauterised mucosa was re-inforced with Fibrin Glue(Mixture of Fibrinogen and thrombin-Tisseel by Baxter).A total of 4 ml quantity was required.The bladder was kept deflated after the injection. The sealing of the fistula tract was confirmed endoscopically and then Foleys catheter was introduced. The plan is to keep patient on NBM for 24 hours and further 24 hours on liquids and then ensure she will not suffer from constipation further.The bladder will be kept deflated for a period of 4 weeks.

Easy solution for the urethral stricture: Urethral stent insertion

2010-04-23T01:28:00.000-07:00

A 48 year old gentleman came with recurrent stricture urethra-proximal bulbar region.He had undergone multiple endoscopic interventions-Optical Internal Urethrotomies and repeated dilatations. Patients flow before the surgery He was also a case of diabetes on oral hypoglycemic agents and thus prone for recurrent Urinary Tract Infections also. His investigations were within the normal limits.His Blood Sugar levels were fairly well controlled. Clinical examination revealed Balanitis Xerotica Obliterans as the cause of the urethral stricture. Retrograde urethrogram showed proximal bulbar stricture. He was given the options of Buccal Mucosal Graft Urethroplasty and urethral stents.The patient was wary of any surgery and opted for day care stent surgery. Memocath stent insertion was done for the patient.Intra-operative assessment of the stricture length was 5.5 cm reaching just near the External Urethral Sphicter.So a 7 cm Urethral stent was inserted just touching the sphincter proximally and covering extra 0/5 cm beyond the stricture distally.This was done keeping in mind the stricture length always extends 5-10 mm beyond the visible stricture(microscopic extension of the disease). After the surgery the patient went into post-obstructive diuresis( a phenomenon noted after relief of long standing obstruction) and so his stay was extended by 2 days and then he was discharged. His urinary stream was good and he was voding with Maximum Flow rate of 49 ml/sec.

General advice for patient with the kidney stone disease

2010-04-20T01:36:00.000-07:00

General Advice for stone patient

Drinking advice:
• Balanced fluids
• 2.5-3.0 liters per day
• Diuresis 2.0-2.5 liters per day
• Specific gravity of urine <>

Foods to be avoided: Cabbage,cauliflower,chicken,meat.fish,salty food,pickle,beer,berries,amla,chickoo,mushroom,brinjal,bhindi,tomatoes,eggs,cucumber,cashewnuts,milk(more than 2 glasses per day),lot of diary products

Foods to be taken: Pineapple juice,carrots,coconut water,karela,barley( preferrable made up of jowar),lime juice( donot take more than 1 ½ glasses per day),Horse gram(you can find out from Maharashtrian cuisine how to make items out of it),almonds,banana

superficial bladder cancer: Trans Urethral Bladder Tumor Resection video

2010-04-10T23:58:00.000-07:00

A 23 –year old gentleman presented with gross total hematuria since 1 month. He was a non-smoker and non- alcoholic. He did not have any comorbidities. The patient was investigated with imaging(ultrasonography) and blood biochemistry and hematological tests. The ultrasonography revealed 3 cm papillary growth in right lateral wall of the bladder and the urine cytology confirmed malignancy. He was taken up for endoscopy which confirmed the clinical diagnosis. With the help of resectoscope; the growth was resected .At the end of the procedure a deep cut was taken to include the muscularis propria to aid in staging of the disease and the further treatment. The final histology came as Ta Grade 2 The patient has been kept on 3 monthly follow-up with check cystoscopy.

Pin down that prostate problem

2010-04-05T23:34:00.000-07:00

Recently, a 75-year old retired Air Force officer contacted me. The Bengaluru-based gentleman said he had a “good ten years left in me”. But he had been harbouring prostate cancer for the last five years and had been advised to leave it alone since it was slow growing. Alarmed, I asked him to rush to Hyderabad for further investigations, only to discover that the cancer had spread to his bones and abdomen. Unfortunately, even today the most common myth about prostate cancer is that since it’s slow growing, it is relatively harmless. However, this is not true. Changes in attitude, lifestyle and advances in medical technology have revolutionised the ageing process and men are leading active lifestyles well into their nineties. The Air Force officer once had a prostate cancer that was curable but his doctor had the wrong attitude. The cancer could end his life “prematurely”. Prostate cancer is most common in middle-aged men. Early detection is possible by a blood test called PSA (prostate specific antigen). PSA is a protein released specifically by the prostate gland into the blood stream. Basically, whenever there is an abnormal activity in the prostate gland, be it enlargement, infection or cancer, the prostate weeps in the form of PSA into the blood stream. If the PSA in the blood rises above 4 ng/ml then a prostate biopsy is essential to confirm the diagnosis. Very rarely the cancer can present as a bump in the prostate and therefore the PSA testing has to be combined by examination of the gland by a urologist. In the early stages, prostate cancer is normally without symptoms. Therefore, conducting a regular blood test for PSA and examination by a urologist should be routine for all men over the age of 50. When the disease is advanced, prostate cancer can cause difficulty in urination, infection and blood in urine. Till recently doctors were reluctant to offer treatment because of the side effects the treatment can cause. Any treatment given can affect both potency and the muscles that control urination. Laparoscopic robotic surgery and sophistication in radiation technology have minimised the complications and side effects and there is no reason why patients should not undergo a treatment to cure the prostate cancer. Recently, a new technique called HIFU (high intensity focused ultrasound) has been introduced in India. This uses high intensity ultrasound waves to destroy the cancerous gland. Since it is a nonsurgical procedure and does not involve radiation it avoids the trauma of surgery and side effects, thereby preserving the quality of life. Since the procedure is least traumatic it can be used on patients with heart ailments, diabetes and blood pressure. In conclusion, prostate cancer can be detected early by a blood test and examination by an urologist. It is advisable that men after the age of 50 should have a yearly prostate check even if they have no complaints. If cancer is detected early, can be cured by non-radiation and non-surgical proceduress.

The writer is the CEO of
Dr Ramayya’s UrologyNephrology Institute and Hospitals

Don’t ignore BED WETTING

2010-04-05T21:52:00.000-07:00

Residual urine, high pressure on the kidneys and bladder irritability could be the first signs of kidney failure.

While working as a urologist, in England, a nurse casually asked me if bed wetting could be a serious problem. I said “Yes, it can be, but depends on the duration and age of the person.” She told me her father, an otherwise fit man, had recently started wetting the bed at night. But he was too embarrassed to see his family doctor. I asked her to bring him to me as soon as possible, since I knew from her description that he was probably dealing with a problem that might have affected the kidney. As expected, on examining the patient I found that a enlarged bladder was the reason behind the bed wetting. A subsequent ultrasound scan revealed swollen kidneys and further blood tests showed that he was in the early stages of kidney failure (accumulation of waste products in the body) which fortunately reversed once his bladder was emptied with a catheter. One of the fallouts of this was that his prostate had enlarged preventing his bladder from emptying. As a result the patient had to undergo laser prostate surgery to solve his problem. How does bed wetting and a failure to empty the bladder result in kidney failure? The kidneys situated on either side of the upper lumbar spine filter the blood. They help retain essential salts and proteins as the blood gushes through them at great speed and lets go of nearly two liters of water together with waste products. The blood isbrought into the kidney at great pressure to allow the filtration process. Once the filtration process is completed urine is produced and falls into the collecting system called calyces and pelvis, which are like funnels. The ureters are tubes, which then ease the urine into the bladder by a gentle wave like action called the peristalsis. For the filtration process to take place effectively the pressure has to be low in the collecting system and even lower in the ureters. Any disease in the bladder or in the outflow tract which creates a high pressure in the bladder to force open the gates can disrupt the filtering process resulting in kidney failure. This can happen in children due to faulty gates (vesico-ureteric reflux), blockage while passing urine called Posterior Urethral Valves and Congenital Urethral Stricture, a problem common among boys. It can also occur in adults due to interference in the nerve supply, due to neurological disease or spine injuries. Failure to empty bladder, transmission of high pressure to the kidneys can result in bladder irritability, which are the first signs of a serious kidney disease. Some children don’t grow out of bed wetting. This is usually of no consequence as they settle with time, but the problem still needs investigating to rule out bladder or kidney problem.

The writer is the CEO of
Dr Ramayya’s Urology, Nephrology Institute and Hospitals

Don’t ignore that BLEEDING

2010-04-05T00:51:00.000-07:00

The presence of blood in urine is indicative of a kidney stone or a tumour in the urinary tract.

Hematuria is the presence of blood, specifically red blood cells, in the urine. Whether the blood is visible only under a microscope or to the naked eye, hematuria is a sign that something is causing bleeding in the kidneys, ureters (tubes that carry urine to the bladder), prostate gland, bladder or urethra.

WHO IS AFFECTED

Hematuria occurs in up to 10 per cent of the general population. The frequency of bleeding may differ. It can indicate various problems in men and women. Causes of this condition range from on-life threatening infections to the more serious kidney, bladder or prostate cancers.

KINDS OF HEMATURIA

There are two types of hematuria, microscopic and gross or macroscopic. In microscopic hematuria, the amount of blood in the urine is so small that it can only be seen under a microscope. A few experience microscopic hematuria that has no discernible cause (idiopathic hematuria). These people excrete a higher number of red blood cells. In gross hematuria the urine is pink, red, or dark brown and may contain small or large blood clots. The amount of blood does not necessarily indicate the seriousness of the problem. As little as 1 millilitre of blood can turn the urine red. Hematuria can also be caused due to jarring of the bladder while jogging or running long distance. This is known as ‘Joggers hematuria’. Reddish urine that is not caused by bleeding is called pseudohematuria. Excessive consumption of beets, berries, or rhubarb; food colouring, pain medication and certain laxatives can cause this.

COMMON CAUSES

Many conditions are associated with hematuria. The most common causes include enlarged prostate, kidney, ureter or bladder stones, kidney disease (Nephritis), prostate infection, trauma (e.g. a blow to the kidneys), tumours or cancer in the urinary system, urinary tract blockages or serious infection like tuberculosis, viral infections and sexually transmitted diseases.Hematuria can also be caused due to rare diseases and genetic disorders.

PINNING THE PROBLEM

Bleeding is classified by when it occurs during urination, which may indicate the location of the problem. If blood appears at the beginning of urination it indicates it is from the urethra or prostate, if it is present throughout urination (total hematuria) it is probably from the bladder, ureter, or kidneys. If blood appears at the end of urination it is indicative of a prostate disease. Family history may reveal inherited predispositions or problems associated with hematuria.When blood is discovered in the urine it is important to consult a urologist or nephrologist. Tests like urine culture, endoscopy, ultrasound scan or CT scan can then be ordered to diagnose the problem.

The writer is the CEO of Dr Ramayya’s Urology, Nephrology Institute and Hospitals

Chasing the big `O'

2010-04-04T22:05:00.000-07:00

About 43 per cent of women are sexually dissatisfied due to lack of arousal and elusive orgasms.

Recently, a young couple walked into my clinic with worried expressions. The couple who had been married for just about a year were under pressure to conceive. But the 22-year-old woman had no sexual desires at all,
which was posing to be a problem. “Doctor, ever since my college days I don’t get aroused, and I thought it was incurable,” she said. And although she had mentioned this to her family doctor earlier, he had chosen to ignore the issue. The anxious couple was worried they wouldn’t be able to enjoy a ‘happy married life’. This couple was not alone. There are several couples, where the woman is sexually dissatisfied. But with the right help, this problem can soon be solved.

INCIDENCE

According to a survey by the American Medical Association, 43 per cent women in the 20 to 50 age group experience problems with arousal, orgasm and sexual satisfaction or in other words known as Female Sexual Dysfunction. While there is no recorded data in India,
the percentage of the problem could be the same.

DISSATISFACTION.

Urologists, behavioural scientists,
and psychologists are looking at medical, cultural and psychological reasons for women’s sexual problems.
The female sexual response cycle consists of four stages — excitement (foreplay), plateau (intense excitement with increase in heart rate and vaginal and breast swelling), orgasm (intense vaginal
and pelvic muscle contraction) and resolution (decrease in heart rate, relaxation of muscles and psychological
need for security). Disruption in any of these phases can lead to dissatisfaction.

CAUSES

While there are many causes the exact reason is still unknown. Alcohol, depression, a partner who can’t be bothered, anxiety, stress, smoking, sexual abuse at a young age, urinary leak, dry vagina are some causes.

RECOGNISING THE PROBLEM

The American Foundation of Urologic Disease recognises four causes of female sexual dissatisfaction.
◗ Sexual desire problem
◗ Sexual arousal problem
◗ Orgasmic disorder
◗ Sexual pain disorder
While the first two are treated by a psychologist, the others are treated by a gynecologist.

TESTS

A vaginal plethysmography can evaluate the blood flow to the vagina, while a vaginal pH testing, commonly performed by gynecologists and urologists can be used to detect bacteria-causing vaginitis. A biothesiometer, a small cylindrical instrument, may be used to assess the sensitivity of the clitoris and labia to pressure and temperature. Readings are taken before and after the subject watches an erotic video.

TREATMENT:

Educating men and women on how to respond to a woman’s psychological and physical stimulatory needs is important. One of the methods used is Hormone replacement therapy (HRT) which aims at restoring hormone levels affected by age. A medical condition that causes diminished blood flow to the vagina must be addressed in light of female sexual dysfunction. There are solutions that can increase the blood flow by dilating clitoral blood vessels. There also a few handheld devices that can be used to increase blood
flow to improve sensitivity, lubrication, and the ability to experience orgasm.

The writer is the CEO of
Dr Ramayya’s Urology Nephrology Institute and Hospitals

Male Menopause Myth or Reality

2010-04-04T21:58:00.000-07:00

With more and more senior citizens living longer, and seeking and demanding healthier more fulfilling lives, the past decade has seen major advances in the perception and medical understanding of changes in physical, mental and emotional health of older men which were previously dismissed as‘normal aging’. It is now possible to distinguish normal age related decline in male hormone (androgen) levels from a clinical condition where a variety of physical, mental and sexual symptoms are caused by low androgen levels – and are thus eminently treatable by androgen replacement therapy. The size of the problem is large; it has been estimated that up to 2.5% of men as young as 40 can be suffering from this, and the condition can be present in 30- 70% of men in their 70s. A survey in 2005 in the four metros found that almost 75% of men above 40 reported some features of hypogonadism (deficiency of sex hormones). The medical community has however, and with good reason, been a bit guarded in recommending casual or nonspecialist diagnosis and treatment. This is because on the one hand the signs and symptoms are subtle and there are no straight forward diagnostic tests with clear-cut normal and abnormal values, and on the other hand treatment can have potentially serious side effects if used indiscriminately or without proper monitoring.Typical symptoms include decreased energy and chronic fatigue, sleep disturbances, mood changes and difficulty concentrating, and reduced sexual drive. Specialist evaluation will show signs of decreased muscle mass, decreased bone density, increased visceral fat and hormonal abnormalities. All these symptoms can clearly also be due to other unrelated causes including financial and health related stress around retirement age, difficulty coping with changing relationships or death of a loved one etc. – all major events which can start impacting one’s quality of life at about the same time. Physical signs of androgen deficiency can similarly be mimicked by the tendency to put on weight in middle age, sedentary lifestyle, alcohol abuse and decreasing androgen levels due to something called the metabolic syndrome – a combination of inter-related disorders which increase the risk of heart disease, diabetes etc. The main features of metabolic syndrome are putting on weight around the waist, high blood pressure, low ‘good cholesterol’ and tendency for diabetes. Recent research has shown that metabolic syndrome and age-related hypogonadism can be both cause and effect of each other. Therefore the potential benefits of recognizing and treating ‘male menopause’ (or Symptomatic Late Onset Hypogonadism, to use the more accurate medical term) include not only improving the overall quality of life and sense of well being, but also prevent more well known killer diseases like heart disease, diabetes,blood pressure etc. That is why experts the world over are coming to the consensus that in the presence of typical symptoms and documented hypogonadism, hormone replacement therapy is valid and effective. There is also a cautionary note however: because the diagnosis requires astute clinical judgement and treatment can have potentially serious side effects (like heart and liver dysfunction and the theoretical risk of prostate cancer), hormone replacement therapy should only be started after excluding anyprostatic abnormality, And be carried out under specialist supervision and lifelong monitoring. Any concern about the prostate at any stage should warrant immediate urology referral. Male menopause is therefore very much a reality and can seriously compromise quality of life for ever increasing numbers of men in their sunset years. But with very effective treatment available we all need to believe that getting old may be natural but feeling old is now optional.

The Writer is the
Clinical Director & Chief of Urology
Dr Ramayya's UrologyNephrology Institute and Hospitals Pvt. Ltd.
Dr.Vishwambhar Nath