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.

URINE INCONTINENCE AMONG WOMEN:TITBITS FROM URO-GYNECOLOGIST

Urinary incontinence is a very common urinary problem in female patients, and one in three women over the age of 60 years are estimated to have bladder control problems. One reason why women are more affected is the weakening of pelvic floor muscles by childbirth.

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They present with urine leak having great impact on quality of life in the sense of social , occupational,sexual & psycological.Urinary incontinence almost always results from an underlying treatable medical condition but is under-reported to medical practitioners

TYPES:

                                     

STRESS URINARY INCONTINENCE:
Stress urinary incontinence is caused by loss of support of the urethra which is usually a consequence of damage to pelvic support structures as a result of childbirth.
It is characterized by leaking of small amounts of urine with activities which increase abdominal pressure such as coughing, sneezing and lifting. 

URGE URINARY INCONTINENCE:
Involuntary loss of urine occuring for no apparent reason with feeling of urgency.Urge urinary incontinence is caused by uninhibited contractions of the detrusor muscle. It is characterized by leaking of large amounts of urine in association with insufficient warning to get to the bathroom in time.
       
MIXED  URINARY INCONTINENCE:
Stress + urge urinary incontinence

OVERFLOW  URINARY INCONTINENCE:
Involuntary loss of urine from an overtly full bladder ,in absence of any urge to urinate.


PHYSIOLOGY:
During urination, detrusor muscles in the wall of the bladder contract, forcing urine out of the bladder and into the urethra. At the same time, sphincter muscles surrounding the urethra relax, letting urine pass out of the body. Incontinence will occur if the bladder muscles suddenly contract (detrusor muscle) or muscles surrounding the urethra suddenly relax (sphincter muscles).

HOW TO DIAGNOSE ?:
Patients with incontinence should be referred to a medical practitioner specializing in this field.Urologists specialize in the urinary tract, and some urologists further specialize in the female urinary tract.

 A uro-gynecologist is a gynecologist who has special training in urological problems in women or female urologist with special expertise in gynecological diseases causing urine problems.
 Family physicians and internists see patients for all kinds of complaints, and are well trained to diagnose and treat this common problem. These primary care specialists can refer patients to urology specialists if needed.

Other important points include straining and discomfort, use of drugs, recent surgery, and illness.

The physical examination will focus on looking for signs of medical conditions causing incontinence, such as tumors that block the urinary tract, stool impaction, and poor reflexes or sensations, which may be evidence of a nerve-related cause.

A test often performed is the measurement of bladder capacity and residual urine for evidence of poorly functioning bladder muscles.

Other tests include:

Stress test – the patient relaxes, then coughs vigorously as the doctor watches for loss of urine

Urinanalysis– urine is tested for evidence of infection, urinary stones, or other contributing causes.

Blood tests – blood is taken, sent to a laboratory, and examined for substances related to causes of incontinence.
Ultrasound– sound waves are used to visualize the kidneys, ureters, bladder, and urethra.
Cystoscopy – a thin tube with a tiny camera is inserted in the urethra and used to see the inside of the urethra and bladder.
Uro-dynamic study– various techniques measure pressure in the bladder and the flow of urine.

Patients are often asked to keep a diary for a day or more, up to a week, to record the pattern of voiding, noting times and the amounts of urine produced.

It can be diagnosed with symptoms , physical examination, urine examination,by an experienced uro-gynecologist .The diagosis may be further confirmed by  cystocopy and/or urodynamic study.

TREATMENT:
Different types of incontinence require different treament modalities.
                               
Treatment options range from conservative treatment, behaviour management, bladder retraining,pelvic floor therapy,, medications and surgery. The success of treatment depends on the correct diagnoses. Weight loss is recommended in those who are obese.

                                          
Exercising the muscles of the pelvis such as with kegel exercises are a first line treatment for women with stress incontinence.
Efforts to increase the time between urination, known as bladder training, is recommended in those with urge incontinence. Both these may be used in those with mixed incontinence.
                                               
A number of medications exist to treat incontinence including:fesoterodine,oxybutynin.Medications are not recommended for those with stress incontinence and are only recommended in those who have urge incontinence who do not improve with bladder training.
Surgery may be used to alleviate incontinence after other treatments have been tried and found not to be effective

 Stress urinary incontinence requires transvaginal tape surgery.

The tension-free transvaginal tape(TVT) sling procedure treats urinary stress incontinence by positioning a polypropylene mesh tape underneath the urethra. The 20-minute outpatient procedure involves two miniature incisions and has an 86-95% cure rate. The transobturator tape (TOT) sling procedure aims to eliminate stress urinary incontinence by providing support under the urethra
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Urge incontinence mostly treated by medications like Anti -cholinergics.

Overflow incontinence requires to relieve bladder outlet obstruction.

ALWAYS A TEAM OF EXPERTS IS MORE RELIABLE

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.