RIRS: REMOVAL OF STONE WITH NITINOL BASKET

A 45 year old man presented with a 6 mm residual calculus in the inferior calyx post ESWL therapy.

We prefer to do RIRS in such patients rather than going ahead with the second session of ESWL. 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.

In cases like this ; where the patient is prestented the ureter is spacious and allows basketing of relatively bigger stone also through the access sheath.We used nitinol basket rather than Holmium LASER lithotripsy in this patient.

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.

DR NAVEENCHANDRA ACHARYA GETS JDDR CERTIFICATE

Because of good reviews and feedbacks from the patients seen in OPD of Ramayya Pramila Hospitals ,Dr Naveenchandra Acharya,Chief Urologist and Andrologist has got JDDR certification endorsed by Amitabh bachchan. 

OUR CHIEF UROLOGISTS INTERVIEW IN "YOU AND I " MAGAZINE

Dr Naveenchandra Acharya , Chief Urologist and andrologist spoke to the journalist of " You and I " magazine regarding the relevent problems in the field of male and female sexual dysfunction prevalent in the city of Hyderabad.He also spoke about the reasons, life style modifications needed to improve potency and the services that Ramayya Pramila hospitals provide to cure such problems. 

SACROCOLPOPEXY AT RAMAYYAS PRAMILA HOSPITALS: SURGERY FOR VAULT PROLAPSE

A 60 year old lady presented with vault prolapse after vaginal hysterectomy.The patient was taken up for sacrocolpopexy ( open Pfannenstiel incision).

The procedure:

The vagina is first freed from the bladder at the front and the rectum at the back. A graft made of permanent synthetic mesh is used to cover the front and the back surfaces of the vagina. The mesh is then attached to the sacrum  as shown in the illustration. The mesh is then covered by a layer of tissue called the peritoneum that lines the abdominal cavity; this prevents the bowel from getting stuck to the mesh. 

T SHAPED SLING MADE UP FROM PROLENE MESH 

DISSECTION OF THE VAULT AFTER PUSHING BLADDER AND RECTUM AWAY 

THE TWO LIMBS OF THE "T" MESH ATTACHED AND ANCHORED TO ANTERIOR AND POSTERIOR VAGINAL WALLS 

Tremendous response for free health camp for kidney diseases at Telephone colony

The Free Urology  Health Camp  was held on 15-04-2013 Sunday at  Telephone Colony; there was a tremendous response to the camp.

The camp was meticulously  planned and well executed.The camp was well attended by the residents of the Telephone colony and adjacent colonies.

Around 100 people were screened during the Camp by Dr.P.Vamsi Krishna and Dr.P.Abdul Fatah. Medicines were provided by the Cipla Pharma Company to the patients at free of Cost.

The Colony Association appreciated Ramayya Pramila Urology Hospital for organizing Health camps and serving Society. Our Doctors were Felicitated by the Colony Association. Eenadu Paper has carried out our news Item in the District Edition.

RIRS AND ESWL FOR RENAL CALCULI IN A SOLITARY KIDNEY

A 45 year old gentleman came with pain in left kidney. He was a case of left solitary left kidney. On evaluation he had three stones - one of 1.6 cm in the left renal pelvis, and two of 5-6 mm in the left middle calyces.

He had come from Malaysia for RIRS and stone clearance. We did RIRS and could clear the renal pelvic stone but as the stone bulk was higher and the kidney was solitary functioning; we decided to stop the procedures once the fragments were scattered to the calyces.

We took him up for ESWL session on the very next day and there was a complete clearance during ESWL. We had to deliver around 3500 shocks to the two calculi.

We have kept a 5Fr DJ stent and planning for stent removal after 1 month.We have asked him to get it removed at Malaysia. 

LASER URETEROSCOPIC LITHOTRIPSY

A patient came  with pain in left flank . On evaluation he was found to have left ureteric calculus located at vesicoureteric junction and one calculus of 5 mm in the upper calyx.

We did URS and used Holmium LASER lithotripsy for clearance of the calculus.We did ESWL for the upper calyceal calculus.

Our Holmium LASER settings for the lithotripsy in the ureteric calculus:

DR NAVEENCHANDRA ACHARYA CONSULTANT UROLOGIST AT RAMAYYA PRAMILA HOSPITAL TO BE HONOURED AT JAPAN

Dr Naveenchandra Acharya has been invited as speaker to the 14th Biennial Meeting of the Asia-Pacific Society for Sexual Medicine (Young scientist's lecture)to be held in Kanazawa, Japan.

This meeting is held at Ishikawa Ongakudo, Kanazawa-city, Ishikawa, Japan from May 31-June 2, 2013

He will be speaking there on the topic on Endothelial Dysfunction in the patients with Erectile dysfunction.

DARTOS POUCH FOR RETRACTILE TESTES

A 7 year old boy presented with bilateral retractile testes.The patient didn't have any other abnormalities.

We took him up for the surgery.The hemiscrotal incisions was given at the root of scrotal pouch.With saline injection a dartos pouch was created and an incision on the dartos and the testicles were retrieved from the incision and the tunica vaginalis was opened.

  

The edges of the tunica vaginalis were sutured to the dartos pouch edges and the skin incision was closed.

INFECTED URETHRAL CYST WITH URETHRAL STENOSIS

A 50 year old woman came with dysuria and painful urination for 6 months.She had persistent pain in the urethral region.

She was seen by a Gynecologist and then referred to us for the management.

We saw a cyst around 2 cm at the urethral meatal region .The cyst was opened and marsupialised. The cystoscopy was performed before and after the surgery and urethral dilatation was done till 11/14 Hegars dilators.

The cyst was causing the narrowing of the meatus. 

We  have decided to keep the catheter for 48 hours and has been started on antibiotic therapy.We have instructed her to avoid sexual act for 2 weeks to prevent scarring of the region because of the trauma.

Urethral cyst:
The urethral cysts are because of the infection and blockage of the duct opening of the skenes gland (paraurethral glands).It appears as glistening , tense and bulging mass at the under-surface of the urethral meatus on the anterior wall of the vagina.Because of the urethral blockage it can cause weak and interrupted stream,misdirected stream, UTIs and dysuria. If infected it can lead to fever and painful micturition and pain at the site of the cyst.  

The important message was the lady continued to take antibiotics; leading to antibioma formation but no relief.A simple vaginal examination diagnosed the condition.It stresses the importance of pervaginal examination for urethral problems.

SERUM PSA MORE THAN 100 ng/ml: A COMMON PRESENTATION OF ACUTE ON CHRONIC PROSTATITS

A 56 year old man presented to us with shivering and fever. He has lower urinary tract symptoms for 2 weeks and was put on prulifloxacin by a general practitioner.

We evaluated him  and found to have tender prostate on DRE. He was then catheterised with 14 Fr Silicon catheter.His hematological and biochemical tests revealed mild leucocytosis; rest all tests were normal.

He had a previous USG; which showed normal prostate size but Post Void Residual urine about 110 ml. His PSA was more than 100 ng/ml. We repeated the test again it was the same.

The patient was educated and once he knew about the high PSA value; he was panicky.As the PSA is invariably correlated with prostate cancer by the laymen.  

We counselled him that most likely it would be prostatic infection and went ahead with the TRUS guided biopsy after the culture report and treating him with IV antibiotics for 48 hours.

The biopsy was negative and revealed active prostatitis. We took him for LASER prostatectomy again after 48 hours of continuous IV antibiotics.

He is doing fine postoperatively.

GENITOURINARY TUBERCULOSIS....A NIGHTMARE FOR UROLOGISTS

            A 29 y gentleman presented with severe storage LUTS, dysuria, hematuria since 3 months.

Examination revealed bilateral epididymal nodules ( he also underwent I&D for scrotal abscess few years ago). His creatinine was raised (1.8), so as the ESR (45). USG revealed left pyonephros with contracted pelvis and dilated and thickened upper ureter and calyces. Bladder was only 40 ml (prevoid on USG). Modified AKT and other antibiotics were started after appropriate cultures and he was taken up for Cystoscopy + left RGP + Lt DJ stenting and bladder mucosal biopsy.

DILATED LOWER END OF URETER WITH LONG SEGMENT PROXIMAL STRICTURE

STRICTURED MID URETER

SEGMENTAL DILATION OF UPPER URETER

DESTROYED PCS ANATOMY WITH CONTRACTED RENAL PELVIS AND MOTH-EATEN CALYCES

After 4-6 weeks of AKT , split renal function will be assessed by renogram and further course of management planned. 

HYDROTHORAX ; A COMPLICATION OF SUPRACOSTAL APPROACH IN PCNL

A 48 year old gentleman underwent bilateral PCNL( simultanoeus and with multiple punctures)The main bulk of the stone was removed with the supracostal and upper calyceal approach.

The patient post-operatively had a drop in saturation after a period of 2 hours.The auscultation was normal during the operation but in the second hour of the operation it was noted that airway pressures had risen and saturation started dropping.We placed  thorax tube  on both sides and 800 ml fluid was drained from left side and 1000 ml was drained from right side.

As there is a drop of saturaion we did it on an emergency basis without going ahead for CxRay. 

BILATERAL ICD IN SITU

Especially supracostal approach carries a higher risk of intrathoracic complications.Prone position is required for PCNL. Munshi et al. reported that they were also not able to recognize hydrothorax in a similar patient until the end of the operation and blamed the prone position. Hydrothorax was realized after the spontaneous ventilation was achieved and the patient was in supine position. 

Technique to avoid hydrothorax:

The puncture should be done after deciding the right calyx and approach to the calyx to be punctured decided ; in a fully expiration.Once the needle is placed and is in perinephric tissues then the final puncture should be done in full inspiration.

POST OPERATIVE PAROTITIS : A BRIEF OVERVIEW

Postoperative parotitis is a frequent and important complication of major surgery. The majority of infections probably are ductogenous in origin, and the responsible organism is the staphylococcus. Bad oral hygiene, dehydration  Vitamin A deficiency (with attendant atrophy of the epithelial cells of Stenson's duct causing  the lowered resistance of the parotid gland) are responsible for Parotitis. 

Preoperative care should include hydration and oral hygiene.

We routinely start Chlorhexidine mouthwash for all patients before surgery.

Postoperative prophylaxis should consist of continuance of oral hygiene, hydration and the institution of active mastication as soon as possible. Treatment after parotitis has developed should be antibiotics; preferably combination of antibiotics against gram positive bacteria (like penicillin group) and anerobic bacteria (like metronidazole).

THULLIUM LASER VAPORISATION AND ENUCLEATION OF PROSTATE IN PATIENTS ON ANTICOAGULANTS AND ANTIPLATELET AGENTS: ONE OF THE BIGGEST SERIES FROM RAMAYYA PRAMILA HOSPITALS

Significant number of patients with bladder outlet obstruction due to BPH are on antiplatelets and anticoagulants. Prostate surgery in this group of patients either in the form of TURP or Open prostatectomy is associated with increased risk of bleeding complications requiring transfusions, packing of the prostatic fossa or ligation or embolization of internal iliac arteries. 

Efficacy of Thulium Laser in the above group of patients is evaluated in terms of perioperative, postoperative and delayed bleeding complications as well as cardiac events in perioperative and immediate postoperative period. 

We Patients 217 with bladder outlet obstruction due to prostatic enlargement on antiplatelets and anticoagulants who underwent vaporisation,vaporesection or enucleation using Thullium LASER REVOLIXX . 

Ecosprin was continued in all patients and clopidogrel was stopped 48 hours before surgery in patients with prostate size of more than 70gms and restarted after 24hrs. Patients on oral anticoagulants were converted to LMWH. Patients with drug eluting coronary stents and high risk of occlusion were started on LMWH in immediate post operative period.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

1. NO OF PATIENTS ON ASPIRIN – 112( 51.6%) 
2. NO OF PATIENTS ON CLOPIDOGREL ALONG WITH ECOSPRIN-96(44.2%) 
3. NO OF PATINETS ON ORALANTICOAGULANTS(WARFIRIN/ACETROM) - 4 ( 1.8%) 
4. LMWH - 5 (2.3%) 
5. NO OF PATINETS ON CORONARY STENTS -42(19.3%) 
6. PATIENTS WITH POST CABG STATUS 21( 9.6%) 
7. LMWH -5 (2.3%) 
8. PROSTATE Gland size 28 gms - 200gmsMean 42 gms 

Post operative Complications

1. IMMEDIATE POSTOPERATIVE BLEEDING COMPLICATIONS 7 (3.2%) 
2. Mean Hb level drop 0.7 g/dl 
3. Transfusion rate 4 (1.8%) 
4. POST OPERATIVE CARDIAC EVENT WITHIN 30DAYS 4 (1.8%) 
5. DVT & Pulmonary embolism 0 
6. DELAYED HEMATURIA WITHIN 6 MONTHS 2(0.9%)