ADVANCES IN LAPAROSCOPY TECHNIQUES AND TECHNOLOGIES

Since the early 1990s, laparoscopic urologic surgeries have evolved from experimental techniques to commonly accepted procedures. Early pioneers in the field used instrumentation and optics that are primitive by today’s standards, but technological advances have made the operations more efficacious and easier to perform. Various devices, including energy sources, vascular staplers, 3-chip cameras, and robotic assistance, have allowed surgeons to perform complex operations with improved confidence.

Conventional laparoscopic camera consists of a 2-Dimensional (2D) system and although there is improvement in graphics from high definition (HD) system, there is still a lack of depth and spatial perception. There is much training needed to master laparoscopic techniques as there is a need to interpret secondary spatial cues such as shadow and motion parallax.

 3-Dimensional (3D) systems may potentially improve laparoscopic training by eliminating the need to overcome the loss of stereoscopic vision.

(Laparoscopy), a modern technique in which an operation in the abdomen is performed through small incisions as compared to larger incisions needed in traditional surgical procedures. This surgical approach addresses the key requirements of Healthcare Reform:

• Increased Quality of Care – Minimally invasive surgery provides better clinical outcomes than traditional "open" surgery.
• Decreased Costs – Numerous industry and clinical studies have demonstrated that minimally invasive surgery provides significant cost savings when compared to a robotic surgical approach.

• Enhanced Patient Satisfaction – Minimally invasive surgery provides less scarring, shorter hospital stays and faster recovery than traditional "open" surgery.

Da Vinci is a computer-assisted robotic system that expands a surgeon's capability to operate within the abdomen in a less invasive way during laparoscopic surgery. This

system allows greater precision and better visualization compared to standard laparoscopic surgery.

The operations with the Da Vinci System are performed with no direct mechanical connection between the surgeon and the patient. The surgeon is remote from the patient, working a few feet from the operating table while seated at a computer console with a three-dimensional view of the operating field.

The physician operates two masters (similar to joysticks) that control the two mechanical arms on the robot. The mechanical arms are armed with specialized instruments with hand-like movements which carry out the surgery through tiny holes in the patient’s abdomen. The arms eliminate any hand tremor by the surgeon and offer motion scaling – allowing extremely precise movements within the patient.

URETHROPLASTY:INDICATIONS AND IMPLICATIONS

In uro-surgery,urethroplasty is the repair of an injury or defect within the walls of the urethra. There are four commonly used types of urethroplasty performed; anastomotic, buccalmucosal onlay graft, scrotal or penile island flap (graft), and Johansen's urethroplasty. 

The choice of procedure is dependent on factors including:

• physical condition of the patient
• overall condition of the remainder of the urethra (not affected by the stricture)
• the length of the defect (best determined by urethrography)
• multiple or misaligned strictures
• anatomical positioning of the defect with regard to the prostate gland, urinary sphincter, and ejaculatory duct.
• position of the most patent area of the urethral wall (necessary for determination of the location of the onlay/graft site, most often dorsal or ventral)
• complications and scarring from previous surgery(ies), stent explantation (if applicable), and the condition of the urethral wall

• availability of autograft tissue from the buccal cavity (buccal mucosa) (primary selection)
• availability of autograft tissue from the penis and scrotum (secondary selection)
• skill level and training of the surgeon performing the procedure

The length-of-stay is usually determined by the:

• status/condition of the patient, post recovery
• after-effects of the anesthesia/sedation/spinal anesthesia utilized during the procedure
• anticipated post-surgical care, per care plan (dressing changes, packing changes, and monitoring of (any) surgical drains - if used)
• monitoring of the newly established urethral cysostomy (Johansen's urethroplasty) if applicable
• monitoring of the supra pubic catheter or foley catheter for signs of infection and proper urine output if applicable
• titration of palliative and anti-spasmodic  medication(s) if applicable
• post surgical complications if any

Ideally, the patient will have undergone urethrography to visualize the positioning and length of the defect. The normal pre-surgical testing/screening (per the policies of the admitting hospital, anesthesiologist, and urological surgeon) will be performed, and the patient will be advised to ingest nothing by mouth, NBM, for a predetermined period of time (usually 8 to 12 hours) prior to the appointed time.

Upon arrival to the preoperative admitting area, the patient will be instructed to don a surgical gown and be placed into a receiving bed, where monitoring of vital signs, initiation of a normal saline IV drip, and pre-surgical medication including i.v anti biotics, and a  sedative.

The patient will be transported to the operating room and the procedures for induction of the type of anesthesia chosen by both the patient and medical staff will be started. The subject area will be prepped by shaving, application of an antiseptic wash (usually povidone iodine), surgically draped and placed in lithotomy position appropriate for surgery on OT table.

Constant monitoring of vital signs including pulse oxymetry are carried out by the anesthesia practitioner until the patient is discharged post-operatively to the post-surgical recovery unit. After sufficient awakening from the anesthetic agent has taken place, and if the patient is a candidate for same day discharge, he (and the person responsible for his transport home) will be instructed in the care and emptying of the catheter and its drainage system, cleansing of the involved area(s) and methods/intervals for dressing change, monitoring for signs of infection and for signs of catheter blockage. The patient will be given prescriptions for an antibiotic or anti-infective agent, and a mild to moderate pain medication (no more than a few days worth of pain is expected). The patient will be instructed to optimize bed rest for the first two days after the operation, be limited to absolutely no lifting, and instructed to consume a high fiber diet and use a stool softener  to help in avoiding straining during evacuation. After days 1 and 2, the patient will be instructed to sensibly increase physical activity, and avoid becoming sedentary. Adequate hydration is essential during the post-recovery phase of the procedure.

In accordance with the preference of the surgeon, a retrograde urethrogram will be scheduled to coincide with the anticipated removal date of the suprapubic or Foley catheter (usually 7 to 14 days post-procedure, however some surgeons will attempt removal in 3 to 5 days).^[16] At 10 days post procedure, the suture line(s) will be evaluated, and the sutures removed if applicable (in many cases, the surgeon will utilize absorbable sutures, which do not require removal)

Urethroplasty is generally well tolerated with a high rate of success, serious complications occur in fewer than ten percent of patients.

• recurrence of the stricture
• infection
• urinary incontinence (symptoms of incontinence often improve over time with strengthening exercises)
• urinary retention requiring intermittent catheterisation to completely empty the urinary bladder
• erectile dysfunction
• loss of penile sensation, decreased tactile sensation of the penile shaft and corona
• retrograde ejaculation, changes in ejaculation, and decrease in intensity of orgasm
• urinary fistula
• urinary urgency
• urine spraying
• hematoma
  
  
  
  
   

STONES AND RENAL FAILURE:DONT IGNORE THIS FACT

Kidney stones are formation of hardened minerals in the kidneys or urinary system.In most cases,it is because of decrease in urine volume or increase in the minerals that form the stones in urine.

Kidney stones in some cases can actually result in a “dead” kidney or kidney failure. The good news though is that this doesn’t happen very often and it often takes a long time to occur, providing the opportunity for treatment to occur before permanent damage occurs.

Kidney stones can cause kidney damage in two primary ways.

An untreated obstructing stone that causes persistent severe blockage instead of successfully passing can eventually cause atrophy in a kidney, resulting in a dilated, thinned out kidney with minimal function.

Thankfully, because most stones are associated with significant amounts of pain, most patients will seek treatment long before permanent damage can occur.

 However, in cases where patients have “silent” stones that cause little or no pain, long term obstruction can occasionally lead to kidney damage. With no symptoms to warn them, these patients often go months to years before a stone is diagnosed.

The CT scan below demonstrates a left kidney which has been damaged by a large obstructing left ureteral stone. For comparison, note the normal size right kidney. The patient did not have any symptoms of pain and the stone was found after the CT scan was obtained for the finding of blood in the urine.

2) Infection related stones, usually composed of struvite and sometimes presenting as a complete “staghorn” can lead to ongoing chronic urinary tract infections that cause damage slowly through inflammation and scarring of the kidney tissue.

One reason why kidney stones don’t often cause chronic kidney disease or failure more often is because in most cases, kidney stones will cause damage to only one kidney. Patients whose other kidney is healthy will usually not develop kidney failure. 

Exceptions to this can occur in cases of kidney stones affecting both kidneys, large infection stones occurring in both kidneys, certain congenital causes of kidney stones, and in patients with only one kidney 

 The most common symptom is severe, fluctuating pain that starts in the area where the kidneys are located, in the lower

 back or side under the ribs. Pain tends to move with the stone. If the stone stops, the pain may stop. Other symptoms

 include:

• Bloody or cloudy urine that smells bad
• Nausea and/or vomiting
• Fever and/or chills
• Burning, painful sensation when urinating

If you have any of these symptoms, please call your doctor. Taking care of kidney stones early can prevent serious

 complications, such as CKD or, in extreme cases,RENAL FAILURE that would require DIALYSIS or a KIDNEY 

TRANSPLANT to replace the function of the kidneys.

Treatment for kidney stones

Determining the type of kidney stone you have is usually done by evaluating a 24-hour collection of urine, or by

 examining a stone after it has been passed. There are several methods of renal stone removal; many don’t require

 surgery. You may even be able to pass a stone by drinking lots of water.

Some of the treatments for kidney stones that are too large to pass, or are causing damage, include:

1.Shock waves that are sent directly to the kidney stone. Extracorporeal shock wave lithotripsy (ESWL) or sound waves is not an invasive treatment, so it doesn’t usually require surgery or a hospital stay.

2.Nephrolithotomy, or percutaneous (meaning “through the skin”) nephrolithotomy, is when the doctor makes a small incision in your back and removes the kidney stone using a nephroscope and lithotripter.

3.Ureteroscopic kidney stone removal is a procedure that uses a scope passed through the bladder to remove a stone that is stuck in the ureter after fragmenting with a holmium laser.

 How can I avoid developing kidney damage from my stones?

The good news is that for the vast majority of kidney stone patients, significant kidney damage is unlikely. To be on the safe side, there are a few steps you can take.

• If you develop a stone episode but do not pass a stone or undergo treatment within a few months, you may want to consider getting followup imaging with your doctor to insure that the stone has actually passed and is not causing persistent obstruction. This is more of a concern for larger stones (greater than 6mm or so).
• Patients with large infection related stones (struvite) are at increased risk for kidney damage from their stones. They should be sure to have their stones treated and need followup to insure infections and stones do not return.

• Work with your doctor to prevent future stones. A Stone prevention plan may include testing for the reason why you are forming stones, diet changes, or in certain cases, medications.

 

LAPAROSCOPIC NEPHRO-URETERECTOMY FOR UPPER TRACT TCC(Transitional Cell Carcinoma)

What is a laparoscopic radical nephroureterectomy?

Laparoscopic radical nephroureterectomy is a minimally invasive surgical procedure to remove the renal pelvis, kidney and entire ureter, along with the bladder cuff, in an attempt to provide the greatest likelihood of survival.

When is this procedure used?

Laparoscopic radical nephroureterectomy is used to treat patients who have transitional cell cancer of the upper urinary tract.

What does this procedure involve?

Unlike a conventional nephroureterectomy, laparoscopic surgery requires only several small incisions. Through these incisions, a surgeon uses a powerful endoscope – a tiny camera – and specialized surgical instruments to remove the diseased organs.

How long does this surgery take?

Surgery takes approximately 3-4 hours, and the hospital stay is usually one to two days. Full recovery usually takes two to three weeks.

What are the advantages of this procedure?

• Reduced hospital stay and faster healing
• Less postoperative pain and less need for pain medication
• Shorter recovery time
• Quicker return to normal activity or work
• Smaller incisions and less scarring

The patient who underwent the above procedure was 45 yr old female presented with one episode of  mild hematuria.She was screened with basic battery of tests which showed  2 cm mass in renal pelvis.
On further evaluation with contrast CT abdomen she was found to have multifocal upper tract TCC(Transitional cell carcinoma).

After informed consent, we have done Left radical nephroureterectomy with a bladder cuff removal through laparoscopy.
Post operative period was uneventful.She had smooth post op recovery and got discharged on day 6 from the hospital.
The followup should be regular in the form of ultrasound,urine for malignant cells, some may require check cystoscopy in view of multi focal nature of the malignancy.

PLEASE DONOT IGNORE ANY BLEEDING IN URINE CALLED HEMATURIA.CONSULT A UROLOGIST TO FIND THE CAUSE AND REMAIN HEALTHY

EMERGENCIES ALL SHOULD KNOW: ABSCESS

 ABSCESS


An abscess is a collection of pus that has accumulated within a tissue because of an inflammatory process in response to either an infection or any foreign material. It is a defensive reaction of the tissue to prevent the spread of infectious materials to other parts of the body.

The final structure of the abscess is an abscess wall, or capsule, that is formed by the adjacent healthy cells in an attempt to keep the pus from infecting neighboring structures. However, such encapsulation tends to prevent immune cells from attacking bacteria in the pus, or from reaching the causative organism or foreign object.

The cardinal symptoms and signs of any kind of inflammatory process are redness, heat, swelling, pain and loss of function. Abscesses may occur in any kind of solid tissue but most frequently on skin surface  or deep skin , in the lungs, brain, kidneys and liver etc. Major complications are spreading of the abscess material to adjacent or remote tissues and extensive regional tissue death. Abscesses in most parts of the body rarely heal themselves, so prompt medical and surgical attention is needed at the first suspicion of an abscess. An abscess could potentially be fatal (although this is rare) if it compresses vital structures such as the trachea, in the context of a deep neck abscess, or in the brain causing altered sensorium.


Wound abscesses can be treated with antibiotics. They require surgical intervention, in the form of incision and drainage, debridement and curettage under anaesthesia cover. It is important to note that appropriate antibiotic therapy alone without surgical drainage of the abscess is seldom effective.The reason being, antibiotics are unable to get into the abscess and their ineffectiveness at low pH levels. Whilst most medical texts advocate surgical incision some medical doctors will treat small abscesses conservatively with antibiotics.


Perianal abscess:
 Perianal abscess can be seen in patients with for example inflammatory bowel disease  or more commonly in diabetes. Often the abscess will start as an internal wound caused by ulceration, hard stool or penetrative objects with insufficient lubrication. This wound typically becomes infected as a result of the normal presence of feces in the rectal area, and then develops into an abscess. This often presents itself as a lump of tissue near the anus which grows larger and more painful with time. Like other abscesses, perianal abscesses may require prompt medical treatment, such as an incision and debridement and drainage through open wound , allowing it to heal on its own reducing the chances of recurrence.