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. 

Health Camp Organised at Uppal

Ramayya Pramila in Media

World Diabetes day Hyderabad and Urologic complications of diabetes- BLUE CIRCLE it for treatment and prevention

World Diabetes Day (WDD) is celebrated every year on November 14. World Diabetes Day was created in 1991 by the International Diabetes Federation and the WHO.

November 14 is the birthday of Frederick Banting who, along with Charles Best, first conceived the idea which led to the discovery of insulin in 1922.

Each year World Diabetes Day is centred on a theme related to diabetes. Diabetes Education and Prevention is the World Diabetes Day theme for the period 2009-2013.

The World Diabetes Day logo is the blue circle - the global symbol for diabetes which was developed as part of the Unite for Diabetes awareness campaign. The circle symbolizes life and health.

India is facing an epidemic of diabetes. At present, confirmed diabetes patients in India are 67 million, with another 30 million in prediabetes group. By 2030, India will have the largest number of patients in the world. Diabetes is not only a blood sugar problem, but brings along other complications as well.

Diabetes and urologic diseases are very common health problems that markedly increase in prevalence and incidence with advancing age

Diabetes is associated with an earlier onset and increased severity of urologic diseases. Apart from increased frequency and severity of urinary tract infections Diabetes is also associated with kidney stone formation, bladder dysfunction, sexual dysfunction and various other renal abnormalities.

Diabetic nephropathy

A complication that occurs in some people with diabetes. In this condition the filters of the kidneys, the glomeruli, become damaged. Because of this the kidneys 'leak' abnormal amounts of protein from the blood into the urine. This can lead to renal failure, cardiovascular diseases and high blood pressure.

Urinary tract infections

Diabetic individuals have a two- to threefold higher prevalence of asymptomatic bacteriuria and are at risk for developing more serious consequences. Emphysematous cystitis and pyelonephritis,relatively rare infections, occur almost exclusively in diabetic patients.

Other clinical manifestations that are unique or strongly associated with diabetes include abscess formation and renal papillary necrosis. 

Bacteremia secondary to UTI and pyelonephritis may also be more common in patients with diabetes.

Also of importance is the fact that many diabetic patients are infected with non–Eschereschia coli species in particular klebsiella and other gram negative rods, enterococci and other group B streptococci.

Additionally, urinary infections and asymptomatic bacteriuria with Candida Albicans occur commonly in diabetic women.

Diabetes and kidney stones

Individuals with type 2 diabetes are at an increased risk for developing kidney stones in general, and have a particular risk for uric acid stones. People with type 2 diabetes have highly acidic urine, and this metabolic feature helps to explain their greater risk for developing uric acid stones

Bladder dysfunction

Over 50% of men and women with diabetes have bladder dysfunction. Current understanding of bladder dysfunction reflects a progressive condition encompassing a broad spectrum of lower urinary tract symptoms including urinary urgency, frequency, nocturia, and incontinence. Symptoms due to BPH are more severe in diabetes patients. Previously, the dysfunction has been classically described as diminished bladder sensation, poor contractility, and increased postvoid residual urine, termed bladder cystopathy . However, bladder cystopathy most likely represents end-stage bladder failure with symptoms of infrequent voiding, difficulty initiating voiding, and postvoid fullness and is relatively uncommon.

Bladder instability or hypersensitivity is the most frequent finding, ranging from 39–61% of subjects. Diminished bladder contractility or sensation has been found less often and an acontractile bladder appears to be quite uncommon.

Male sexual dysfunction

Erectile dysfunction (ED) occurs in a substantial number of men with diabetes, with prevalence estimates ranging from 20 to 71%. In men with diabetes, the relative risk for ED increases with poor glycemic control, duration of diabetes, and the number of other nonurologic complications of diabetes (i.e., retinopathy, nephropathy, and limb loss).

Phosphodiesterase-5 inhibition leads to significant improvements in function in 50–70% of type 1 and type 2 diabetic patients with ED and controlled hyperglycemia. However, the efficacy is reduced compared with nondiabetic populations. Nonresponders to oral treatment benefit from intracavernosal injections of prostaglandin-E1 and related agents, as >80% of men with diabetes develop adequate penile rigidity.

Effective surgical interventions in such cases are limited to penile implants. The risk of periprosthetic infection after implantation in diabetic men ranges from 3.2–15%.

Femalesexual dysfunction

Female sexual dysfunction is associated with biological, psychological, and social determinants. It includes disorders of desire/libido, arousal, inhibited orgasm, and sexual pain. Prevalence increases with age, cardiovascular disease, diabetes, cancer, hysterectomy, and neurological conditions.

Who is at risk for developing sexual and urologic problems of diabetes?

Risk factors are conditions that increase the chances of getting a particular disease. The more risk factors people have, the greater their chances of developing that disease or condition.

Diabetic neuropathy and related sexual and urologic problems appear to be more common in people who

• have poor blood glucose control 
• have high levels of blood cholesterol 
• have high blood pressure 
• are overweight 
• are older than 40 
• smoke 
• are physically inactive 

Can diabetes-related sexual and urologic problems be prevented?

People with diabetes can lower their risk of sexual and urologic problems by keeping their blood glucose, blood pressure, and cholesterol levels close to the target numbers their health care provider recommends.

Being physically active and maintaining a healthy weight can also help prevent the long-term complications of diabetes. 

For those who smoke, quitting will lower the risk of developing sexual and urologic problems due to nerve damage and also lower the risk for other health problems related to diabetes, including heart attack, stroke, and kidney disease.

Review of your medication,Certain medicines can affect the kidneys as a side-effect which can make diabetic kidney disease worse. For example, you should not take anti-inflammatory medicines unless advised to by a doctor. You may also need to adjust the dose of certain medicines that you may take if your kidney disease gets worse.

Urine leak in elderly men and women

Urine leak in elderly

Urine leak afflicts unto 30% of older people living at home. It is associated with embarrassment, stigmatization, isolation, depression, anxiety and risk of institutionalization. It predisposes to perineal rashes, ulcers, urinary tract infections, urosepsis falls and fracture. Also the cost of management of geriatric incontinence is high. Despite these considerations geriatric incontinence remains neglected by patients and physicians alike or dismiss it as a normal part of growing old. But it is abnormal at any age. More ever its increased prevalence relates more to age associated diseases and functional impairment than to age itself.

Regardless, incontinence is usually treatable and often curable at all ages even in frail elderly but the approach differs significantly from that used in younger patients.

Pathophysiology

At any age, continence depends on integrity of lower urinary tract and presence of adequate mentation, mobility, motivation and manual dexterity. lower urinary tract changes with age even in the absence of disease. Bladder controllability, sensation and ability to postpone voiding decline in both male and female. 

However there are more changes in female urethra w.r.t sphincter, pelvic muscles and length of urethra.

Involuntary bladder contraction increases in both sexes and elderly often excrete most of the fluid intake at night.

There may be associated prostate enlargement and obstruction of outflow due to prostate, renal disease, heart failure etc. The above changes predispose to urine leak.

In most of the cases the onset or exacerbation of urine leak is probably due to precipitants outside lower urinary tract that are amenable to medical treatment and treatment of these precipitants alone may be sufficient to restore incontinence.

Transient urine leak

Incontinence is transient in upto one third of elderly and more than half of hospitalized patients. Although termed incontinence it may persist if left untreated.

Urinary tract infections(UTI) are commonest cause of transient urine leak when urgency and burning sensation are so prominent that the older person is unable to reach the toilet before voiding. Incontinence is occasionally the only symptom of UTI and traetment of UTI resolves the incontinence.

Atrophic urethritis and vaginitis causes incontinence and urine leak in upto 80% of elderly women with incontinence. It is associated with urgency and occasionally sense of scalding that mimics a UTI and also exacerbates stress incontinence. Recognizing atrophic vaginitis is important as it may respond to low dose estrogen. This also prevents recurrent UTI's. 

Stool impaction (chronic constipation) may cause both fecal and urinary incontinence in 10% of older individuals. Disimpaction and healthy bowel habits restores continence.

In addition many drugs are associated with urinary incontinence. Excess urine production due to diuretics, caffinated beverages, diabetes and congestive heart failure may lead to incontinence , treatment of which corrects incontinence.

Incontinence due to lower urinary tract abnormality

Bladder(detrusor) over activity is the most common type of lower urinary tract dysfunction in a incontinent male or female elderly. It occurs due to increased spontaneous activity of bladder muscles. Over activity may be due to central nervous system abnormality or due to bladder abnormality. Anticholinergics, injection therapy helps in most of the cases.

Incontinence in the setting of outlet obstruction is second most common cause of incontinence in older men.

It may be due to urgency or overflow and treatment of enlarged prostate  relieves the symptoms.

In older women urethral stenosis due to fibrotic changes and atrophy may lead to incontinence. resolves by use of low dose estrogen cream and dilatation.

Stress incontinence is second most common cause of incontinence in women. Occurs due to birth and operative trauma and also due to age related atrophy. stress incontinence can be cured by sling surgery, pelvic exercises injection therapy etc.

Evaluation of urine leak involves identification of contributing factors lab testing for kidney functions. Urodynamics is strongly considered in certain group of patients with bladder weakness and over activity.

Successful treatment of urine leak in elderly is usually feasible.

Treatment of contributing factors such as medications and systemic problems can improve the incontinence.

Incontinence due to obstruction is treatable by removal of obstruction such as prostate surgery.

Multifactorial creative, persistent and optimistic approach increases chances of successful outcome.     

LARGE BLADDER CLOT EVACUATED ENDOSCOPICALLY BY MORCELLATOR

A 79 y gentleman underwent spine surgery and was put on LMW Heparin for DVT prophylaxis. On the post operative day 3, his PUC was removed and he went into retention. Foley's reattempted but failed leading to bleeding per urethra.
Urologist opinion was then sought.PUC was attempted only once by Urologist but could not succeed. Patient  was counselled for SPC and risk of hematuria due to concomitant use of LMW Heparin therapy. Trocar SPC was done under LA at bedside and around 1 litre urine drained. Later he developed repeated SPC blockage due to clots which were flushed at regular intervals by bladder wash syringe.
 Later it was decided to shift the patient to our center from outside facility,for cystoscopy and clot evacuation. On cystoscopy there was a false passage in bulbar urethra and obstructive prostate with  huge  clot in the bladder. As the bladder was already tense, any use of Elliks evacuator will increase the chances of  bladder rupture. Hence the massive clot was removed by Morcellator completely under anaesthesiologist cover.