UROLOGY HEALTH CAMP BY RAMAYYA PRAMILA UROLOGISTS IN OLD CITY HYDERABAD

Ramayya pramila urology and laparoscopy hospital has conducted a urology health camp for men women and children of old city area of hyderabad on 7th december 2014.

There was excellent response to the camp which was well organised by our practice development manager in collaboration with neo-care diagnostics near high court.

Dr.Bhargava reddy patiently saw a good number of patients with urology and andrology problems and advised them with appropriate tests and medications.

Dr.Sarika, our expert uro-gynecologist examined and advised the women with urology ailments regarding medications and surgeries as needed.

With this over whelming response we got request from helping hand foundation to conduct a camp for their poor and needy patients which will be done in january 2015.

HERNIA:WHAT IS HERNIA?WHY AND WHEN SHOULD IT BE TREATED?

Hernia
A hernia is the protrusion of an organ or portion of an organ through the wall of the cavity that normally contains it. The inguinal canal is found in the groins of both men and women. In men, it is the area where the spermatic chord passes from the abdomen to the scrotum. This chord holds up the testicles. In women, the inguinal canal contains a ligament that helps to hold the uterus in place.


There are different kinds of hernias, each requiring a specific management. By far the most common hernias develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or "defect", through which omentum, or abdominal organs covered with peritoneum, may protrude in the form of hernia.


Hernias may or may not present with either pain at the site, a visible or palpable lump, or in some cases more vague symptoms resulting from pressure on an organ which has become "stuck" in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed or accompanied by an organ. protrude.


Symptoms and signs vary depending on the type of hernia. Symptoms may or may not be present in some inguinal hernias. In the case of reducible hernias, a bulge in the groin or in another abdominal area can often be seen and felt. When standing, such a bulge becomes more obvious. Besides the bulge, other symptoms include pain in the groin that may also include a heavy or dragging sensation, and in men, there is sometimes pain and swelling in the scrotum around the testicular area.


Irreducible abdominal hernias or incarcerated hernias may be painful, but their most relevant symptom is that they cannot return to the abdominal cavity when pushed in. They may be chronic, although painless, and can lead to strangulation (loss of blood supply) and/or obstruction (kinking of intestine). Strangulated hernias are always painful and pain is followed by tenderness. 
  The conditions that increase the pressure of the abdominal cavity may also cause hernias or worsen the existing ones. Some examples would be: obesity, straining during a bowel movement or urination (constipation, enlarged prostate), chronic lung disease etc.

Also, if muscles are weakened due to old age,poor nutrition,multiple pregnancies,previous surgeries on abdomen etc. hernias are more likely to occur.

By far the most common hernias (up to 75% of all abdominal hernias) are the so-called inguinal hernias. Inguinal hernias are further divided into the more common indirect inguinal hernia (2/3, depicted here), in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia type (1/3), where the hernia contents push through a weak spot in the back wall of the inguinal canal.

UMBILICAL HERNIA:They involve protrusion of intraabdominal contents through a weakness at the site of umbilicus through the abdominal wall. Umbilical hernias in adults are largely acquired, and are more frequent in obese men and women. Abnormal decussation of fibers at the line alba  may contribute.Umbilical hernia occurs in babies under 6 months of age which becomes obvious when the baby cries.Typically, this hernia goes away on its own by 1 year of age.

Surgery is usually recommended for most types of hernias to prevent complications like obstruction of the bowel or strangulation of the tissue,Muscle reinforcement techniques often involve synthetic materials like mesh. The mesh is placed either over the defect (anterior repair) or under the defect (posterior repair). At times staples are used to keep the mesh in place. 

Laparoscopic surgery is also referred to as "minimally invasive" surgery, which requires one or more small incisions for the camera and instruments to be inserted, as opposed to traditional "open" or "microscopic" surgery, which requires an incision.Many patients are managed through day surgery centers, and are able to return to work within a week or two, while intense activities are prohibited for a longer period. 

OVERACTIVE BLADDER:A CURSE FOR CHILDREN,MIDDLE AGED MEN AND WOMEN,

The hallmark symptom of overactive bladder is urgency, but the diagnosis also includes frequent urination, frequent interruptions of sleep because of the need to urinate -nocturia, and urinating unintentionally followed by an urge to continue urge incontinence.

Overactive bladder has many causes which can include diseases such as diabetes, medications such as diuretics, or lifestyle choices such as excessive consumption of caffeine or alcohol Bothersome urinary symptoms that are related to neurological such as multiple sclerosis are generally treated differently from overactive bladder in people who do not have neurological problems

People with the condition often have the symptoms for a long time before seeking medical care. Pain while urinating suggests that there is a problem other than overactive bladder.Management of overactive bladder is addressed in terms of quality of life since it is not a life-threatening problem.Overactive bladder is characterized by a group of four symptoms: urgency, urinary frequency, nocturia, and urge incontinence. Urge incontinence is not present in the "dry" classification.


The causes  of OAB is unclear, and indeed there may be multiple causes. It is often associated with overactivity of the detrusor muscle, a pattern of bladder muscle contraction observed during uro-dynamic study. It is also possible that the increased contractile nature originates from within the urothelium and lamina propria, and abnormal contractions in this tissue could stimulate dysfunction in the detrusor or whole bladder. Treatments for OAB are usually synonymous with treatments for detrusor overactivity. OAB is distinct from stress incontinence, but when they occur together, the condition is usually known as mixed incontinence.
Diagnosis of OAB is made primarily by ruling out other causes of overactivity of the bladder such as an infection or bladder tumor.  Additionally, urine culture may be done to rule out infection. The frequency/volume chart may be maintained and cystoscopy may be done to exclude tumor and stones. If there is an underlying metabolic or pathologic condition that explains the symptoms, the symptoms may be considered part of that disease and not OAB.


Treatment for OAB includes nonpharmacologic methods such as lifestyle modification (fluid restriction, avoidance of caffeine), bladder retraining or may involve the use of pharmaceutical agents such as anti muscarinic drugs.

Studies have shown that few people get complete relief from overactive bladder drugs and that all available drugs are no more than moderately effective. A typical person with overactive bladder may urinate 12 times per day. Medication may reduce this number by 2-3 and reduce incontinence events by 1-2 per day.

ADVANCES IN LAPAROSCOPY TECHNIQUES AND TECHNOLOGIES

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

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

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

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

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

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

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

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

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

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

URETHROPLASTY:INDICATIONS AND IMPLICATIONS

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

The choice of procedure is dependent on factors including:

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

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

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

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

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

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

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

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

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

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

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

STONES AND RENAL FAILURE:DONT IGNORE THIS FACT

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

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

Kidney stones can cause kidney damage in two primary ways.

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

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

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

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

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

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

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

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

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

 include:

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

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

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

TRANSPLANT to replace the function of the kidneys.

Treatment for kidney stones

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

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

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

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

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

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

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

 How can I avoid developing kidney damage from my stones?

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

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

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