URO-MAP( MINIMAL ACCESS PROCEDURES IN UROLOGY) WORKSHOP FOR UROLOGISTS IN THE STATE HELD AT RAMAYYA PRAMILA UROLOGY AND LAPAROSCOPY HOSPITAL

We are glad to announce that our prostate surgery workshop held on 2nd nov-2014 has been a run away success among the budding and practicing urologists.

We have selected 3 modalities of prostate surgery for BPH(Benign prostate hypertrophy)

1. THULIUM LASER
2. HOLMIUM LASER 
3. TURIS

The workshop was graced by veteran Dr.Vyas narayana rao, a well known,respected and accomplished urologist who formally inaugurated the workshop at 10.00AM on 2nd nov 14.

The first case was done by DR.RAMESH RAMAYYA using thulium laser (REVOLIX).The patient is a known case of mild mitral regurgitation with 150gm prostate.

He was administered combined spinal and epidural anaesthesia and the surgery was well demonstrated with simultaneous question answer session from the visiting urologists with DR.RAVI KUMAR co-ordinating from the auditorium to OT. The surgery concluded in 2.5 hrs and the prostate chips morcellated succesfully with RWOLF morcellator and 2 way 18F foley catheter was inserted and received wide spread applause from the audience.

There was a talk by expert engineer MR.RAJIV BHINDRA who detailed about the physics of lasers and urologist must-know tips on laser benefits and precautions to be taken with laser prostatectomy.

The talk was followed by delicious lunch appreciated by all delegates.

The post lunch session started with 2nd case of 80gm prostate.DR.MALLIKARJUN REDDY was the operating surgeon using Luminous Holmium laser.There was healthy discussion between the surgeon and audience comparing the two lasers in doing effective prostatectomy.The surgery went well and ended with morcellation of prostate lobes and 18F foley 2way catheter.

The 3rd case was a patient with high PSA(Prostate specific antigen) of 10.5 and 50 gm prostate posted for TRUS Biopsy(trans rectal ultra sound) along with TURIS(Trans urethral resection of prostate in saline) using bipolar cautery.The trus was excellently demonstrated by senior radiologist DR.SASHIDHAR PRASAD who cleared common doubts of delegates while doing the procedure.

The TURIS resection of prostate was performed by DR.SARANGAM a senior urologist from warangal,Telangana.The surgery was neatly done and discussed the cost-effectiveness of the TURIS over lasers.

The workshop which had 50 urologists attending was widely apprciated by one and all and ended with Vote of thanks by DR.T.SHIVAPRASAD,Hospital superintendant and anaesthesiologist.There was a request for another workshop by the MCH/DNB urologists in february 2015 which was approved and promised by the RAMAYYA PRAMILA UROLOGY AND LAPAROSCOPY HOSPITAL TEAM.

SORAFENIB IN ADVANCED RENAL CELL CARCINOMA

A 50 Year old gentleman presented with caudate lobe metastases after 1 year of left radical nephrectomy and IVC thrombectomy.

The patient had also IVC involvement as diffuse thickening at the hepatic veins confluence.As the recurrence was appearing irresectable a plan was made to start sorafenib 200 mg twice a day and review with MRI scan after a period of 3 months.

Sorafenib has been approved for treatment of advanced renal cell carcinoma.An article in New England Journal of Medicine published January 2007, showed compared with placebo, treatment with sorafenib prolongs progression free survival in patients with advanced clear cell renal cell carcinoma in whom previous therapy has failed. The median progression-free survival was 5.5 months in the sorafenib group and 2.8 months in the placebo group.

It works with inhibition of tyrosine kinase and Raf kinase pathways.

There are many side effects of this molecule. Our patient developed a strong hand and foot syndrome for which the drug had to be stopped temporarily.He developed rectal bleed too.

Other side effects that have been documented are hypophosphatemia,thrombocytepenia,anemia , altered liver enzymes .

We have decided to stop sorafenib temporarily till the hand and foot syndrome resolves and then to reintroduce the medication in low dosage .If the patient tolerates the drug then reinstitute the drug therapy in full dosage.

      

RAMAYYA PRAMILA HOSPITAL DOCTORS BAG FIRST PRIZE AT EUSC2013

Our doctors presented a paper on " Thulium Laser vaporization and enucleation in patients on antiplatelets and anticoagulants" in the 2 nd Annual Emirates Urological Society Conference held at Abudhabi..

A total of 250 patients were included in study and the outcome was very favourable insptite of patients being prone to bleeding and cardiac events during and post-operatively.

The paper was highly appreciated and conferred on 1 st prize.

  

UROFLOWMETRY - THE BEST SCREENING TEST IN UROLOGY

                  Uroflowmetry is a simple, noninvasive, reliable, repeatable and cost effective investigation to screen for and diagnose lower urinary tract abnormalities. Any person suffering from various urinary disturbances need this simple test to look for any abnormalities in voiding. In this test, one has to pass urine in a specialised funnel that is connected to a flow sensor.

• Elderly(>50 y) men undergoing non-urological surgeries may have underlying bladder outlet obstruction secondary to prostatomegaly. 
• Healthy men above 50 y also need this test as a part of general health checkup to identify obstruction at an early stage so that it complications like renal failure, retention, stones, bleeding and infections can be prevented.
• People with symptoms can be better assessed by this test and the treatment can be significantly guided by the findings on this test.

Uroflowmetry Machine

Normal pattern - to severely impaired flow patterns

Intermiitency

LASER PROSTATECTOMY FOR 17O GM PROSTATE IN A HIGH RISK PATIENT

 A 60 year old gentleman came to us with prostate enlargement and renal failure. He was on maintenance dialysis for the kidney ailment. His prostate was phenomenally large in size (170 gm).The patient was having severe urinary tract infection amenable only to a last line antibiotic -colistin (Multi Drug Resistant organism). He was kept on catheter by almost 4 months and considered to be a very high risk case by doctors outside. We did prostatectomy successfully using Thulium LASER technology. This remarkable feat was achieved in a single session and the patient was discharged within 48 hours of the surgery. He is now free of catheter and the infection.
Conventional method of doing prostatectomy (Trans Urethral Resection of Prostate – TURP) has limitations in such cases. As the size increases; the complications like bleeding and fluid overload also increase. Proceeding ahead with TURP in such cases would have been fraught with the risk of life threatening intra-operative and post- operative haemorrhage.
Currently Ramayya Pramila is the only centre with Thulium LASER facility in whole Andhra Pradesh. We are the pioneers in the field of LASER applications in urology. We were the first ones to use LASER technique for prostate removal way back in 2008.  This centre can boast of treating many such cases again testimony to the fact that the size of the prostate is of no consequence with this wonderful technology. This technology provides respite to high risk patients like patients on blood thinners, aged and frail patients with heart ailments who otherwise cannot be operated with routine methods.
Thulium LASER prostatectomy with morcellation provides significant reduction in bleeding, morbidity and hospital stay. We usually keep the catheter for 24-48 hours (a tube that drain the bladder) and discharge the patient within 48 hours. This is in total contrast to routine TURP where catheter and stay is prolonged (3-5 days) notwithstanding the complications like bleeding.

Slowly this technology is gaining widespread acceptance amongst urologist all over the world. We use smaller diameter endoscope for the surgery and therefore the incidence of post-operative stricture (narrowing because of damage to the urinary tract during the surgical procedure and hence recurrence of urinary problems) is low. It also safely preserves the continence and erectile function of the patients. 
We have done a total of 1250 cases till now using this LASER. Many of the cases were referred to us by cardiologists because of their cardiac problems. Some of patients were on drug eluting stents. In this group of the patients; blood thinners cannot be discontinued. Routine TURP in such patients would have been highly risky. A few were also referred by our fellow urologists; the reason being a large size of the gland. The complications like bleeding, blood transfusing was almost nil. We also did 2 patients in local anaesthesia (pudental block) as they were deemed unfit for any major anaesthesia.
We feel proud to declare that one of our urologists-Dr Naveenchandra Acharya-got first prize for paper on LASER prostatectomy on such high risk patients. He presented a data of 250 such procedures at European Urology Association Meeting held at Abudhabi. The paper was critically acclaimed at the summit. This will pave a way for acceptance of this technology amongst our colleague urologists.
We strongly feel that Thulium LASER is the new emerging platinum standard for prostate surgery and should be adopted by health care professionals for its versatile and superior technology.