LASER TURBT: THULIUM LASER FOR TURBT

A 45 year old patient presented to us with hematuria,dysuria and left flank pain.On investigations we found that he had a 3 cm lesion over the left vesicoureteric junction with left hydro-ureteronephrosis.

We took him up for LASER TURBT.The tumor was covering the orifice. We used 70 W setting and did the complete resection of the tumor.The ureteric orifice could be detected after the completion of the TURBT. We did the stenting for the left side and sent the specimen for histopathological analysis.

The bladder is a hollow organ in the lower abdomen. It stores urine, the urine produced by the kidneys. Urine passes from each kidney into the bladder through a long cylindrical tube called a ureter. Urine leaves the bladder through another tube, the urethra. 

Understanding bladder cancer 

The wall of the bladder is lined with cells called transitional cells and squamous cells. More than 90 percent of bladder cancers begin in the transitional cells. This type of bladder cancer is 

called transitional cell carcinoma.  Cancer that is only in cells in the lining of the bladder is called superficial bladder cancer. Cancer that begins as a superficial tumors may grow through the lining and into the muscular wall of the bladder. This is known as invasive cancer. Invasive cancer may extend through the bladder wall. It may grow into a nearby organ such as the uterus or vagina (in women) or the prostate gland (in men). It also may invade the wall of the abdomen. When bladder cancer spreads outside the bladder, cancer cells are often found in nearby lymph nodes. If the cancer has reached these nodes, cancer cells may have spread to other lymph nodes or other organs, such as the lungs, liver, or bones.Some of the lymph node spread like para-aortic lymph nodes or nodes at the aortic bifurcation may denote the metastatic disease precluding surgery and indicating the need of chemotherapy rather than a curative option. When cancer spreads from its original place to another part of the body, the disease is metastatic bladder cancer. Less than 10% of the carcinomas are squamous cell carcinoma or adenocarcinoma. In underdeveloped nations, SCC is associated with bladder infection by Schistosoma haematobium(In india, this infection is found at the coastal belt of Maharashtra region) . Adenocarcinomas account for less than 2% of primary bladder tumors. These tumors are observed most commonly in exstrophic bladders and respond poorly to radiation and chemotherapy. Radical cystectomy is the treatment of choice. Small cell carcinomas are extremely aggressive tumors associated with a poor prognosis and are thought to arise from neuroendocrine stem cells. 

Pathophysiology:

The World Health Organization classifies bladder cancers as low grade (grade 1 and 2) or high grade (grade 3). Tumors are also classified by growth patterns: papillary (70%), sessile or mixed (20%), and nodular (10%). Carcinoma in situ (CIS) is a flat, noninvasive, high-grade urothelial carcinoma. The most significant prognostic factors for bladder cancer are grade, depth of invasion, and the presence of CIS. Upon presentation, 55-60% of patients have low-grade superficial disease, which is usually treated conservatively with transurethral resection and periodic cystoscopy. Forty to forty-five percent of patients have high-grade disease, of which 50% is muscle invasive and is typically treated with radical cystectomy. 

Bladder cancer: Who's at risk? 

No one knows the exact causes of bladder cancer. However, it is clear that this disease is not contagious. People who get bladder cancer are more likely than other people to have certain risk factors. Still, most people with known risk factors do not get bladder cancer, and many who do get this disease have none of these factors( so a clear cut cause and effect relationship may not be obtained in all cases). Doctors always find themselves in dilemma when a patient asks why he got the disease and ends up in answering a multi factorial cause for the cancer. Studies have found the following risk factors for bladder cancer: 1. Age. The chance of getting bladder cancer goes up as people get older. People under 40 rarely get this disease. 2. Sex: Men are likelier to get the disease than the females(3-4:1) 3. Tobacco. The use of tobacco is a major risk factor. Cigarette smokers are two to three times more likely than nonsmokers to get bladder cancer. Pipe and cigar smokers are also at increased risk.  4. Occupation. Some workers have a higher risk of getting bladder cancer because of carcinogens in the workplace. Workers in the rubber, chemical, and leather industries are at risk. So are hairdressers, machinists, metal workers, printers, painters, textile workers, and truck drivers. 5. Infections. Being infected with certain parasites(like scistosomiasis) increases the risk of bladder cancer. 6. Treatment with cyclophosphamide or arsenic. These drugs are used to treat cancer and some other conditions. They raise the risk of bladder cancer. 7. Race. Whites get bladder cancer twice as often as African Americans and Hispanics. The lowest rates are among Asians. 8. Family history. People with family members who have bladder cancer are more likely to get the disease. Certain genes have been identified as the cause for the development or progress of the disease. Symptoms of bladder cancer 

Common symptoms of bladder cancer include: 

• Blood in the urine (making the urine slightly rusty to deep red), • Pain during urination • Frequency, or urgency. • Dysuria- especially if Carcinoma in Situ has been the cause • Weak stream: especially if bladder neck region is affected as in our second case. • Flank pain: In case of bladder tumor blocking one of the orifices the kidney can get swelled up(Hydro-ureteronephrosis) and the patient can have the flank pain because of that reason. These symptoms are not sure signs of bladder cancer. Infections, benign tumors, bladder stones, also can cause these symptoms. Anyone with these symptoms should see a doctor so that the doctor can diagnose and treat any problem as early as possible. 

Diagnosis of bladder cancer 

• Physical exam -- The doctor feels the abdomen and pelvis for tumors. The physical exam may include a rectal or vaginal exam; this is useful in advanced disease spreading to the pelvic wall precluding probably a complete resection(so called R0 resection). 

• Urine tests -- The laboratory checks the urine for blood, cytology.

• Intravenous pyelogram/ CT UROGRAPHY: The radiologist injects the dye(radio-contrast one) to delineate the kidneys and bladder region mainly for assessing the upper tracts. As the bladder cancer has a tendency for a field change (it may affect many regions of the genitourinary tract simultaneously or metachronously) the imaging can detect such changes. The CT urography/MRI is now-a-days more and more resorted to for its reliability in staging the local disease.It also vaguely indicates the lymphnode status  

• Cystoscopy – An endoscope is inserted into the bladder through the urethra to examine the lining of the bladder. The patient may need anesthesia for this procedure as the same sitting can be utilized for diagnosis/biopsy/complete resection of a superficial tumor. 

Staging 

The following is the TNM staging system for bladder cancer: • CIS - Carcinoma in situ, high-grade dysplasia, confined to the epithelium • Ta - Papillary tumor confined to the epithelium • T1 - Tumor invasion into the lamina propria • T2 - Tumor invasion into the muscularis propria • T3 - Tumor involvement of the perivesical fat • T4 - Tumor involvement of adjacent organs such as prostate, rectum, or pelvic sidewall • N+ - Lymph node metastasis • M+ - Metastasis More than 70% of all newly diagnosed bladder cancers are non–muscle invasive, approximately 50-70% are Ta, 20-30% are T1, and 10% are CIS. Approximately 5% of patients present with metastatic disease, which commonly involves the lymph nodes, lung, liver, bone, and central nervous system. Approximately 25% of affected patients have muscle-invasive disease at diagnosis.  

Treatment • Ta, T1, and CIS Endoscopic treatment

  Transurethral resection of bladder tumor (TURBT) is the first-line treatment to diagnose, to stage, and to treat visible tumors. 

 Patients with bulky, high-grade, or multifocal tumors should undergo a second procedure to ensure complete resection and accurate staging. Approximately 50% of stage T1 tumors are upgraded to muscle-invasive disease.This procedure is called as Relook TURBT and is usually undertaken after a period of 4 weeks to restage the disease 

 Because bladder cancer is a polyclonal field change defect, continued surveillance is mandatory with IVP/CT Urography for upper tract affections.

Cystolithotrispy and Bladder neck incision by AURIGA 30 W LASER

A 40 year old  gentleman presented with obstructive lower urinary tract symptoms with on and off hematuria.On evaluation ; he was found to have severe obstructive flow with 2 cm calculus in the bladder.His  prostate was 18 gm in size on ultrasound evaluation( it correlated with the DRE findings of flat prostate).

He was taken up for cystolithotripsy and Bladder neck incision. The anterior urethra was normal .The bladder neck was high and the bladder was tarbeculated ( Grade 2 trabeculations).The ureteric orifices were normal and there was a 2 cm stone in the bladder( smooth surface).

We used Auriga 30 W LASER ( From STARMEDTECH from Germany) for the bladder neck incision and cystolithotripsy.

OUR ENDOUROLOGIST DR VAMSHIKRISHNA PERFORMING THE SURGERY

 

 

The advantage of Auriga 30 W is that it delivers high power pulses which is ideal for the stone fragmentation and disintegration. It also can be used for the soft tissue applications like LASER excision of the urethral stricture, bladder neck incision and smaller prostates.

 

INTERMITTENT SELF CATHETERISATION

Self catheterization has revolutionized the treatment of neurogenic bladders. It is a safe , time tested and effective way of managing urinary retention or urge incontinence .It has transformed the lives  people crippled with neurogenic bladders or obstructive uropathies.
This involves catheterization by a suitable catheter by the patient himself/herself at regular intervals so as to empty the bladder.
Few indications for the self catheterization are:
1) Neurogenic /hypotonic bladder  causing chronic urinary retention.This could be due to diabetes, multiple sclerosis,sacral cord pathology,spinal cord injuries etc.
2) High pressure retention : which can result in reflux nephropathy and renal damage .
3)Obstructive retention: In patients who are wheel chair bound and too frail to undergo surgery and suffering from prostatomegaly and retention ; intermittent self catheterization is a better modality of treatment. In patient who are infirm and debilitated and don't have carer to do the intermittent catheterization we usually keep indwelling supra-pubic catheter.
4) in patients with stricture urethra : follow up cases to prevent recurrence of the stricture.

How to do the self catheterization : tips from Ramayya Pramila:
We use Nelaton 14 Fr catheter for the urinary emptying.
We demonstrate the methodology to the patient or the carer fro effective implementation.
The Nelaton should be amply lubricated with xylocaine jelly.
In females: a trained female nurse demonstrates the self catheterization to the female patient encouraging the use of mirror to visualize the urethral; meatus properly
We have trained male and female nurses who exclusively do teaching , demonstrating the correct way and following up the patients doing the CISC.

The major drawback of CISC is if done incorrectly ; it can lead to trauma or infections( incomplete emptying leads to stagnation and infection).The bleeding( pain) and infection can result in patient dropping out from the CISC regimen. This can have very serious repercussions.

The patients are evaluated fully clinically( Focal Neurological Assessment- for dermatomes and their sensitivity, anal tone etc), urodynamic test( to know the chances of upper tract damage due to high pressure bladder), urine culture and imaging studies etc. If needed we prefer to supplement anticholinergic medication to keep the reflex bladder contractions  low. 




  

URETHRAL CALCULUS CAUSING URINARY RETENTION

Male urethra is 18 cm in length and is divided into three parts:

Prostatic urethra: encompassed by the prostate gland .This part of urethra extends from the bladder neck to the external urethral sphincter.

Membranous urethra: This is the part of urethra inside the perineal membrane .

Anterior urethra: It is divided into penile and bulbar urethra. The meatus is the opening of urethra on the tip of the glans. The submeatal part is the narrowest part of the urethra.

We had a 40 year old gentleman who presented to us with calculus stuck at the submeatal portion of the urethra. He had painful retention. We did suprapubic aspiration of urine with IV cannula  and then shifted him to OT.There was submeatal narrowing. So  we did a meatotomy and stone extraction. The cystoscopy was essentially normal.

 

 

WHAT IS LAPAROSCOPIC OPERATION, AND ITS ADVANTAGES

A surgical operation is like a work of art, the purpose is not only to treat the disease but also to heal with minimal pain. Laparoscopy is a boon for surgeons and patients alike, as very small cuts are made on the belly, to insert a thin, lighted tube to look at the internal organs.

Advantages of laparoscopy
-Smaller incisions-as small as 5 mm
-Minimal blood loss
-Reduction of infection
-Negligible postoperative pain, patients are can walk 2 hours after the surgery
-Speedy recovery, much faster than open surgery
-Early return to normal activity. Patients go back to their office in around 1 week, they can drive and take the stairs
-Minimum respiratory and digestive complications, as breathing and eating is not restricted because of the pain

The wonders of technology when applied to surgery continue to surprise the patients and doctors alike, but here they are all pleasant ones. The biggest reward for a surgeon is when a patient remains pain free and returns back to routine life as fast as a patient without any surgery.

Scar after open surgery

End result after laparoscopic surgery - minimal scars

HIBISCUS IN PREVENTING UTI( URINARY TRACT INFECTIONS)

Hibiscus has been used in Africa and Asia for treating UTI.Tea brewed from Hibiscus sabdariffa ( green flower envelope).The hibiscus has been used as acidic and antibacterial drug to prevent , treat and deodorise Urine and urine infections.It has also been used to prevent stones.

The flower and calyx of Hibiscus contains bacteriostatic polyphenols like flavonoids and proantocyanidins.  

According to in vitro  research the hibiscus extract has both antifungal and antibacterial( E. Coli and Candida).It has also been compared to Cranberry extract .It has been found that it has more antifungal properties as compared to the later.

In a double-blind, placebo-controlled, clinical trial, women taking hibiscus experienced a 77% reduction in UTIs.  All of them had a history of frequent UTIs .

Plant product effectivity:

In 2009, a group of researchers compared antibiotics head-to-head with daily supplements of cranberry extract in women suffering from recurrent infection.Cranberry (500 mg) and antibiotics (100 mg trimethoprin) were shown to be almost equally effective in preventing UTIs.

REMEMBER TO CRYOPRESERVE THE SPERMS BEFORE ANY MALE INFERTILITY PROCEDURES

A 35 year old gentleman case of obstructive azoospemia underwent Vaso-Eididymal Anastomosis.

 SURGICAL PROCEDURE:

High hemiscrotal vertical incision given extending into the external inguinal ring.The testis was delivered out and the vas was isolated.The scarred vasal tissue was excised and freshened till healthy margins.The proximal vasal patency was confirmed with saline flush test.The  head of the epididymis was chosen for VEA. On microscopy the tubules were looking healthy , turgid and yellowish.

 

The vas was brought till the head region and approximated to the tunic with 8-0 prolene. A longitudinal 2-suture intussusception VEA approach was done. A two parallel double-arm sutures were placed in the distended epididymal tubule with 10- Nylon suture (Ethicon 3313); however, the needles are not pulled through. A nick was made on the distended tubule and the epididymal fluid was tested for sperm. The fluid was tested positive for the sperms and given for cryopreservation. The 2 needles within the epididymal tubule are pulled through, and all 4 needles are placed through the vas lumen at the allowing the epididymal tubule to be intussuscepted into the vasal lumen, completing the anastomosis . The vasal adventitia is then approximated to the epididymal tunic with 8-0 nylon.

VEA is the microsurgical procedure for treatment of epididymal obstruction. It is the most difficult microsurgical procedures for the treatment of male infertility and requires excellent microsurgical skills. 

In India ; most cases of epididymal obstructions are post inflammatory( due to recurrent epididymitis).So we encounter a lot of fibrosis in that region as contrary to what Western population see .In Developed nations , VEA is most often performed for vasectomy reversal or the block is focal. So the results of VEA are high in  US/European countries.( 80-90%) whereas here it is 30-50%.
We also get the successful outcome in only 30-40% cases. Most of the cases need ART afterwards in some or other forms. 
So we advise strongly to all people who undergo VEA, vasectomy reversal, varicocelectomy for severe/azoospermia   for cryopreservation.These cryopreserved sperms can be used  for future ICF and ICSI if need be .
We have seen some patients having genetic problems like AZF c gene disorders where there is continuous deterioration of sperm counts.Such patients ( if they have coincidental varicoceles) undergo varicocelectomy can have adverse outcome not because of the surgical complication but because of the underlying genetic disorder.
Also the complex microsurgical reconstructive procedures may not succeed so the sperm banking is an essential step to be undertaken. 

We are one of the few centers in Andhra Pradesh who regularly perform VEA,vasectomy reversal and mcirosurgical varicocelectomy as part of andrological reconstructive surgeries. We routinely call our embryologist during such procedure. We employ either sperm fluid from the vassal end/epididymal tubule or TESA ( during varicocelectomy) to use for cryopreservation.

ESWL IN MORBIDLY OBESE PATIENTS

A  40 year old gentleman came with right flank pain. He was found to have right upper calyceal calculus of 9 mm.He had morbidly obese body predisposition.

He was a known case of hypertension otherwise he didn't have any other comorbidities. His biochemical and hematological tests were normal. He was evaluated by our cardiologists .His cardiac evaluation was normal.

In Ramayya Pramila hospital it is routine protocol to evaluate all patients cardiologically if they are above 50 years, history of hypertension, diabetes and high BMI( obese or morbidly obese).

 In morbidly obese patients, since the kidney and stone are at a considerable distance from the skin (compared to non-obese patients) difficulty may be found in positioning the patient so that the stone is situated at the focal point of the lithotripter. So focusing these stones is a challenging task. Also the anesthesia itself carries a significant risk. 

 

 

It has been noticed that even the stone is kept within 3 cm of the focal distance( extended focal distance) the ESWL can be carried out. We did this case and got a very good focusing and fragmentation on real time imaging.

HYDERABAD PERFORMS ITS FIRST LAPAROSOCPIC CHOLECYSTECTOMY IN 10 MONTH OLD CHILD

A child 10 months old was diagnosed with cholelithiasis.The presentation was recurrent abdominal colic.The other hematological and biochemical parameters of the child were normal. The child was investigated for any hematological disorders like sickle cell disorder. The decision as taken for the laparoscopic cholecystectomy. Anaesthetic consideration: The baby was monitored closely for end tidal CO2 ,Peak Inspiratory Pressure(PIP), pulse oximetry and the blood pressure.To prevent any barotrauma the intra-abdominal pressure was kept between 7-12 mm Hg.As the children are prone for hypercarbia due to quick absorption of Co2 ; the minute ventilation was increased to keep the baby on hypocarbia side.( ETCo2 was kept between 28-32 mm Hg and Pa Co2 between 31-35 mmhg). The baby was catheterized before the start of the procedure and also the nasogastric tube was kept.The prophylactic antibiotic cefotaxim and normetrogyl. Surgical consideration: The surgery especially the laparoscopic surgeries in infants should be done in optimum time as the delay can compound the hypercarbia problem. The four port approach was adopted.The infraumbilical smile incision was taken and open port insertion was done.A 10 mm port was inserted.Rest 3 ports of 5 mm were inserted as depicted in the picture.

The port insertion was done in anti-Trendelenburg position.The Calots triangle was carefully dissected and the usual cholecystectomy was carried out. Background:The laparoscopuic cholecystectomy as such is very rare in infants.With the abundant usage of abdominal ultrasound in colics such cases are bound to increase in future. The physiological and anatomical considerations in infants make the laparoscopic cholecystectomy a special case.Extreme precautions and care should be excercised during and after the surgery.

Kidney and urinary stone

RADIATION EXPOSURE IN UROLOGISTS: SAFETY PRECAUTIONS

Urology has essentially become endo-urology now-a-days. With the advent of endo-urology; open urological procedures have become less and less common in day to day urological practice.

In endo-urology the use of fluoroscopy is a necessary part. The radiation exposure although in most cases is not direct there is definitely secondary exposure due to radiation scatter phenomenon.  

If the operating surgeon is screened for radiation exposure with the thermoluminiscent dosimetry; it has been calculated that the total radiation exposure is not significant. If we assume that urologist on an average performs 50 PCNLs per year then studies have shown that the scatter radiation does not   exceed 10 mGy. This amount is less than 2% of permissible annual limits of equivalent dose to the extremities.

Hellavel GO et al...Radiation exposure and the urologist: what are the risks? J Urol 2005

 

But  Medical personnel should be aware of scatter radiation risks and minimize radiation exposure when involved in fluoroscopic screening procedures.Dosage minimizing imaging protocols should be strictly followed: 

Using the C-ARM judiciously when needed.

Avoiding continuous C-ARM exposure as far as possible.

use of radiation shield without fail.( it is very common practice not to use the shield in smaller procedures)

thyroid shield ,increased distance from the beam,gloves,glasses,beam collimation , use of mini-C-ARM etc  

the thermoluminiscent dosimetry should be used to calculate the scatter radiation exposure regularly to assess the risks

 

The maximum yearly whole body exposure is around 5000 mrem.( this is the limit for the torso while hands it is 55000 mrem) While 1 hour usage of Fluoroscopy ( unprotected ) is 1100 mrem.So the urologist should employ all the possible startegies- radiation shield, modified drapes,radioprotective gloves to minimize the radiation scatter.

The urologist should be cognizant with the concept of  time,distance and shielding to minimize the risk of radiation scatter.

 

 

Wearing

ESWL IN LARGE PELVIC CALCULUS: EXCELLENT RESULTS IN SELECT CASES

A 30 year old lady presented with left flank pain on and off.On investigation she was found to have a large calculus 21 mm in renal pelvis( USG and X Ray).
She was offered the option of PCNL but she was reluctant for the same.We offered her ESWL with DJ stenting and explained her the possible need of PCNL ( in case of non fragmentation), RIRS and multiple sessions of ESWL.

We did ESWL and there was excellent fragmentation on real time imaging obviating any need of secondary procedures.
We take into consideration certain aspects like... body habitus , stone location ande density as compared to nearest bony landmarks etc.

The X Ray characteristics of the stone can give a fair idea to the treating urologist about the stone fragmentation chances after ESWL.

We have seen that the pelvic stone, irregular stone, stone having a density less than tip of the 12th rib; if these criteria are met then even a borderline stone for PCNL also we have taken up for ESWL and got excellent results.We keep stent in all big stones for ESWL. If stone doesn't get cleared totally we do secondary  RIRS.

....

Mete UK, Naveen A. Ranagnathan P et al. Can X-ray KUB replace costly CT density measurement of renal stones to predict fragmentation buy ESWL? J. Endourol. (Abstract) 2004, 18 (Suppl) A-110.

There are certain protocols we follow :

1) we ensure good sedation/anesthesia: for effective administration of optimum shock waves ; the patient needs to be totally comfortable.Any compromise in intensity can  affect the outcome and add the morbidity of secondary /auxiliary procedures like second/third session of ESWL,PCNL or RIRS.

2)We ensure pre-operative antibiotics,  sterile urine culture and bowel preparation

3)The stone is continuous focussed on real time imaging and the whole procedure is continuous monitored by Urologist.This goes a long way in achieving good fragmentation and pulverisation. The failure of ESWL may not be always because of the hard stones ; it can sometimes because of losing focus, failure to continuously monitor the stone pulverisation.

Dornier machine what we possess has excellent and proven results  even in bigger calculi...

if properly done we can avoid the auxiliary/invasive procedures...This is an excellent data of how Dornier machine can clear even bigger calculi.

 Stone free rates based on stone size and location for ESWL of solitary kidney stones, using Methodist Hospital's Dornier HM3 Lithotripter

Stone location and size	0-10 mm	11-20 mm	21-30 mm
Pelvis	316/351 (90%)	225/272 (83%)	48/59 (81%)
Upper Calyx	53/69 (77%)	21/28 (75%)	8/12 (67%)
Middle Calyx	61/76 (80%)	12/17 (71%)	1/2 (50%)
Lower Calyx	253/317 (80%)	60/103 (58%)	6/19 (32%)

TWISTED OVARAIN CYST:AN EMERGENCY

A 30 year old lady presented with intermittent acute pain in right iliac fossa since 3 days. The pain was severe and needed administration of Fortwin and Phenergan for the pain relief.

The In House Gynecologist checked the patient.There was tenderness in right iliac fossa   but as such the P/V and per-speculum examination was normal.

Her menses had just begun so the congestive pelvic pathology was also suspected. Accordingly antibiotics and anti-inflammatory medications  were started.    

She underwent imaging and essential biochemical and hematological tests. There was a 8 cm right adnexal cyst with intact flow( on Doppler test).

We did a contrast enhanced CT scan for the anatomical delineation of the cyst and its relationship with the adjacent organs.

CT revealed right hydro-ureteronephrosis and bilateral small calculi .The ureteric dilatation was till the right pelvic brim.  The wall of the cyst was thick.

We took her for laparoscopic cystectomy. The patient  had undergone three surgeries( two LSCS and one open appendecictomy).As we suspected right ureteric encroachment by the cyst and pericystic inflammation ; we pre-stented the right ureter.  

There were a plenty omental and intestinal adhesions.We had to do the adhesiolysis first to reach the pelvis.

The ovarian cyst was twisted along with the ovary.The cyst was appearing   tense with bluish hue( haemorrhagic).We removed the cyst in toto and concluded the surgery by doing the ovariopexy to lateral pelvic wall.

The surgery was uneventful.The cyst wall was sent for histopathological analysis.

PCNL IN CHILDREN

There is a general belief that the pediatric population are less prone to stone formation as compared to adults. We used to see more of bladder stones in the pediatric age group .Many a times in the children the stones are attributed to the metabolic abnormality. Malnutrition( Protein Energy Malnutrition is the common cause for bladder stone formation in children).

 

The stones in pediatric age group are more and more seen in private urology set up. The kidney stones are also more often seen now-a-days. We have usually used ESWL as the treatment of choice in pediatric age group but certain things compel us for surgical intervention ( PCNL):

1) Bigger calculi

2) If the patient is from a far off place then repeated ESWL/STENTING and stent removals and follow-ups is impractical. In  such cases PCNL can be assorted to ...to make them stone free at once.

3) Upper calyceal calculi : ESWL can at times is risky because of lung injury( even after covering the lung fields with the polystyrene sheet) 

 

More often the urologists are compelled for PCNL for the want of ESWL machine.

With the advent of mini PERC, ultra- mini-PERC and Micro-PERC the PCNL has become less invasive and can be done in children with less blood loss and post -operative pain.We do routine Mini or Micro PERC in children( when it is required) .

 

MINI PERC BEING PERFORMED WITH 15 FR SHEATH AND MINI-NEPHROSCOPE

OUR PAEDIATRIC UROLOGIST DR VAMSHI DOING THE PCNL

Mini PERC :

 

 Stones in Miniature percutaneous (mini-perc) access was first described in the pediatric population by Jackman et al (1997) as an alternative to standard PCNL. Generally, it consists of downsizing to smaller percutaneous access sheaths with the intention of decreasing blood loss, postoperative pain, and the hospital stay in patients undergoing nephroscopic procedures.The access was done through posterior-inferior calyx. A J-tip PTFE guide wire was placed in the system.

 

Serial dilatation was done till 15 Fr and 15 Fr Sheath was introduced. The sheath has a offshoot Luer-Lock outflow for reduction of intra-pelvic pressure so as to reduce the incidence of sepsis.A wide angle straight forward telescope 12 ° with angled eyepiece (Karl Storz, Tuttingen, Germany) was used as nephrosocpe.Holmium LASER energy was used as energy for stone dis-integration.

30 W THULIUM LASER : A HANDY TOOL FOR UROLOGISTS

Traditionally, the gold standard for treatment of BPH has been the electrocautery based TransUrethral Resection of the Prostate (TURP).But TURP is fraught with complications like bleeding(upto 30%),clot retention,residual prostate ,urethral stricture and TUR syndrome(syndrome characterised by fluid retention and hyponatremia). Because of TUR syndrome usually size of the prostate is limiting factor for the TURP.The TURP is usually not resorted to prostates more than 80 gm in size.Till now the TURP was supposed to be the Gold Standard for prostate resection. However, the LASER technology is safer in this aspect as the co-agulation is better and it uses Normal Saline during resection unlike TURP which uses Glycine(main reason for TUR Syndrome). Potential advantages of laser therapy over traditional TURP include decreased morbidity(bleeding is less than 2%) and shorter hospital stay(stay can be less than 48 hours while in TURP it can be 4-5 days). There are several techniques for laser prostatectomy that continue to evolve. 

Amongst all Thulium appears to be superior in terms of technique,its ability to vaporise( hence usage in cardiac ,anticoagulated and patients on antiplatelet agents),low learning curve ( so friendly for budding urologists unlike its counterpart Holmium LASER where the learning curve is long), precise planes( its well known fact that Holmium LASER prostatectomy is fraught with danger of losing planes and hence problems like extravasation, conversion to TURP or abandoning the procedure altogether).

 

But the Thulium LASER is expensive and cannot be used for stone fragmentation.Holmium LASER can be used in both prostate and stone diseases.

But there is a hope for urologists now.They can have both Thulium ( not 100 /150 w but 30 W) and Holmium 30 w so both stone and prostate can be tackled ( having the best of the both worlds).

The both machines are cost effective.There was initial criticism and apprehension regarding the 30 W LASER thinking that when Thulium LASER is being introduced in 100/120 and 150 W LASER buying anything less than 50 W would be a step backwards.There was a notion regarding the effectivity of 30 W LASER.Hence we decided to use 30 W LASER ; we did 20 cases ( size of the prostate 30-75 gm) .We did enucleation technique or tangerine technique for all patients.We even performed surgeries on cardiac patients with antiplatelet therapy.But the outcome was good.The enucleation was satisfactory and the prostatic fossa was wide.The only disadvantage was the LASING time was delayed.

   

THULIUM LASER VAPORESECTION: A BOON FOR PATIENTS WITH HEART DISEASE( ESPECIALLY PATIENTS ON ECOSPRIN/ ANTICOAGULANTS)

A 70 year old gentleman came to us with refractory urinary retention.He has triple vessel CAD and was drug eluting stent for the same.

He had a moderate prostatomegaly ( 50 gm ) and the cardiologist insisted on continuation of antiplatelet agents( Ecosprin/  clopidogrel).

We took him up for the Thulium LASER prostatectomy .In such cases we usually go for vaporesection rather than the routine enucleation procedure. In certain cases we even do the vaporization( especially in older patients where the main aim is getting the channel rather than prostatic tissue for histopathological analysis).

The surgery went on well without any bleeding or peri-operative cardiac events. The catheter was kept for 48 hours and then it was removed. The patient passed urine successfully.

We have done around 270 such patients with a very favorable outcome.  

MICROSURGICAL VARICOCELECTOMY :A HOPE FOR HOPELESS

Microsurgical varicocelectomy(MSV) is inguinal and sub inguinal exploration of the cord and ligating the veins( pampiniform plexus) under suitable magnification( 10-15X).

OUR ANDROLOGIST DR NAVEENCHANDRA ACHARYA PERFORMING MSV 

Clinically detectable varicoceles associated with abnormal semen parameters normal female partner or female partner with potentially curable infertility problem.

Palpable varicoceles in adolescent boys when accompanied by ipsilateral testicular atrophy.
We have also got encouraging results from MSV from patients with azoospermia( Non -obstructive specially with high normal FSH and late maturation arrest or hypospermatogenesis on testicular biopsy)

Procedure:

We prefer the subinguinal approach.We give a 2 cm incision on subinguinal area.

 

We isolate the cord and lift it with the Babcocks forceps.We open the cremasteric box and isolate the veins.We preserve the testicular artery( sometimes we need to use papavarine especially if the artery goes into the spasm),vas, lymphatics and nerves.

ITS ESSENTIAL TO IDENTIFY THE TESTICULAR ARTERY( TO PREVENT TESTICULAR ATROPHY),LYMPHATICS( TO PREVENT HYDROCELE),NERVES( TO PREVENT ANY NUMBNESS)

The cremasteric box is closed and the incision is closed with the subcuticular stitches. 
With the advent of IVF and ICSI many patients go for these procedures without proper andrological evaluation.Even the gynecologists think that the varicoceles repair the outlook is gloomy.But in contrast it has been consistently noted ( two randomized controlled trials prove it) that the MSV not only improves the sperm parameters, pregnancy rate( and the take home baby rate) but also has a role to play in non-obstructive azoopsemia ( with favourable histopathological biopsy - like late maturation arrest/ hypospermatogenesis and near normal inhibin and FSH).We have cases were the sperms have appeared in azoospermic individuals.
We also firmly believe that the patients with azoospermia with grade 3 varicoceles with even bad histopathological patterns on testicular biopsy like Sertoli only cell pattern also can benefit in terms of improving the yield of TESA during IVF cycle.
Thus MSV can improve the fertility potential of man.The procedure is a day care procedure( the patients are kept for few hours or  24 hours), no side effects and complications.The recuperation rate is fast especially in subinguinal   procedure.The patient can go back to work within a week and resume the sexual act within 2-3 weeks.The sperm count usually takes 3-6 months for the improvement.The procedure is cost effective if the cost of the IVF and ICSI procedures are considered.Also  if the patients sperm parameters are improved; not only he can have hopes for natural conception but also it will help the couple for successive pregnancies.This advantage is not there in IVF procedures.
The aim of any medical and surgical procedure should be to restore the normal anatomy and physiology of the patient as it is the right of the patient.
 

HOW DO WE INDUCE PNUEMOPERITONEUM

We follow open pneumoperitoneum method for laparoscopy.It is safe,quick and easily reproducible method.

We go through the infraumbilical zone in thin patients while in obese patients we go laterally.

 

SOY PRODUCTS HEALTH BENEFITS

Soyabean is classified into the oil seed rather than pulse.It is widely grown in East Asia countries.

Various products that have been used are :

Fermented- soya sauce, soya paste

Non - fermented- Soya Milk, tofu, soya floor,soya oil etc

 

Soya is rich in isoflavones,genistein,alpha-lenolenic acid  and phytic acid. Basically the protein in the soy is heat stable protein so it resists the breakdown after cooking. The carbohydrates in soya bean are stachyose,raffinose etc. which can lead to  gas formation and flatulence in few individuals but fermentation leads to destruction of these poorly digested carbohydrates. So fermented soya products don't lead to flatulence.

 

 

Because of high content of antioxidants ; they are healthy products  and can decrease stress levels, improve the cognitive function.

Isoflavones and genistein can help in chemoprevention.It has found to be beneficial in breast cancer and prostate cancer patients.

We in Ramayya Pramila believe in role of nutrition and neutraceuticals lot in management of many diseases.We advocate health life style for all our  patients.

Specially in prostate cancer patients we stress upon change of life style like- daily walk for atleast 40 minutes, inclusion of dark green leafy vegetables in the diet, and soya products.The genistein in soya has been found to have a role in cancer chemoprevention as far as prostate cancer is concerned.

 

 

There has been a lot of misconception of phytoestrogens( in soya products) leading to feminization ( erectile dysfunction and infertility ) in male patients .A meta-analysis of 10 trials( 2010) have found that the soya products don't alter   the levels of testosterone in patients.

 

BUMPS AND LUMPS IN THE SCROTUM

There are many reasons for the swellings over the scrotum .They can be as simple as skin swellings( furuncles, sebaceous  cysts) , innocuous conditions like hydrocele,spermatocele and epididymal cyst.

sometimes harmful and dangerous conditions like testicular tumor can disguise themselves like these conditions.

We had a 70 year old gentleman presenting to us with huge left hemi scrotal swelling. The patient had undergone hydrocele repair 3 months back. His ultrasound revealed epididymal cyst measuring around 8 cm in dimensions.

We explored the hemiscrotum and excised the cyst in Toto.

 

 

Epididymal cyst:

 

These cysts arise from behind of the testicle from the epididymis. These  cysts can be as small as peanut to large like grapefruit.( like in above said case).

These are common in mid aged individuals but can arise in younger population also. They are usually asymptomatic but if these grow large they can cause discomfort.

The pain, fever and tenderness etc. can happen if the cyst gets infected.

We usually avoid excision in symptomatic individual if the patient is young. As the cyst is in the sperm conducting pathway ; any excision of the cyst can compromise sperm transport. We resort to  aspiration when it causes discomfort because of the cyst.

In older individual we go for hemi scrotal exploration and excision of the cyst.  

 

 

 

New Drug to treat Premature Ejaculation

Dapoxetine shows efficacy in the treatment of premature ejaculation (PE), according to a new study for the treatment for PE.

Dapoxetine, a short-acting selective serotonin re uptake inhibitor, significantly improved all aspects of PE.

They have studied 1,162 men aged 18 years and older who had PE for at least six months. The investigators randomized subjects to receive placebo or dapoxetine 30 or 60 mg on demand (one to three hours prior to intercourse) for 24 weeks.

At baseline, all men had an intravaginal ejaculatory latency time (IELT) of two minutes or less in 75% or more intercourse episodes. All Premature Ejaculation Profile (PEP) measures and IELTs improved significantly with dapoxetine compared with placebo at week 12 and week 24. 

The most common adverse events (AEs) observed were nausea, dizziness, diarrhea, and headache. .