The prostatic enlargement:Everthing about the prostate,the disease and the tretament.How we do prostate surgery in Dr Ramayyas Centre

The following types of myths and misconceptions or inorance about the Benign Prostatic enlargement are prevalent.

1) we had a patient , 50 year old who came to us for prostate surgery.He was referred by a general practitioner for the surgery.He was thinking that LASER treatment will also prevent further development of carcinoma.The common prevalence of thought(rather myth) in general publics mind that LASER/TURP radically ablates the prostate and hence the prostate will not remain inside the body.The article also gives the anatomy and explains why the carcinoma can arise in tissue compressed as capsule(pseudo one) during LASER surgery.


2) Every patient of prostatectomy(LASER) think that they will invariably lose their manhood after the surgery.IT is true that some patients report sexual dysfunction(3-33%) and but not all.Infact those patients with severe Lower urnary tract symptoms(LUTS) prior may even improve their sex life because many a times severe LUTS mars the sexual life rather than prostate surgery.There are now medications which can do away impotence developing after prostate surgery.






3) Retogarde ejcaulation(dry ejaculation)should be explained to each patient.Sex is important part of life so concealing/hiding this aspect of life ;the man may become totally disappointed with the outcome although he may void in superflow.
In young patients with robust sexual life and small prostate we rather do LASER bladder neck Incision than prostate enucelation(impotence rate 20% and ejaculatory dysfunction 6-50%)






4)Many patients think that the prostate recures again(to some extent yes around 17-20% at the end of 8 years).There belief is because of mainly recurrence in form of stricture(OIU-STICTUROTOMY).This also for the patient is recurrence.Sometimes in large gland some residual tissue is left behind which grows within 2-3 years.These common complications of routine conventional Trans Urethral Resection of the Prostate are less common with LASER as it enuceates and removes the prostate till capsule.And the Thulium LASER which we use ; uses the sheath of 22.5 Fr rather 26 Fr used in TURP .Bigger is the sheath more are chances of stricture and vice-versa.
5)one more belief is that prostate removal 100% ensures relief from lower urinary tract symptoms.Infact 70% patients do improve but other patients may not because of presence of age related detrusor(Bladder fault) dysfunction and development of a new detrusor instability(De novo).So it is essential to explain to patient regarding these things.

6)Many patients report after they undergo general body check-up; they come across the finding of enlarged prostate in ultrasonography.Worried about its effect (mainly sexual life.In general people mind prostate is a sexual organ and secondly constant stressing about prostate cancer especially by western media/medicos/western colleagues) they come to us in a panicky mode.All prostatic enlargements donot need surgery(Infact there is no relationship between symptoms and size ).They may have to undergo DRE and serum PSA as part of the screening nothing apart from that.If the size gland is big(more than 70 gm or so) the randomised controlled studies and longitudinal studies have shown these people have more chance of urine retention and therefore surgery so progression is likely.These people can be kept under medical line of treatment if asymptomatic(dutasteride) or alpha-blocker and dutasteride combination if symptomatic.The prostate size per se donot make them a candidate for surgery.
7)PVR:Post Void Residual Urine:I have seen people literally keeping in mind their PVRs since last 8-10 years.They keep a diary also about the same.Sometimes becoming restless that PVR has increased by 30ml in last 3 months; sometimes rejoicing about decrease in PVR by few mls.
There are certain things that needs to be mentioned:
1) PVR doesnot correlate with signs ans symptoms of BPH
2) It maynot predict outcome of surgery
3) It may not denote future damage of kidney because of retention.
4) There is huge intra-individual variability limiting its use to predict the tretament.






ONLY ONE THING IS CERTAIN HIgH PVR PREDICTS IS HIGHER FAILURE RATE WITH WATCHFUL WAITING IF THEY CROSSOVER TO SURGERY AT A LATER PERIOD OF TIME.










The anatomy of the prostate gland:

The prostate is a walnut-shaped gland that forms part of the male reproductive system.The prostate is situated around the urethra - the tube that carries urine from the bladder out of the body.The normal prostate weighs around 18 gm ;3 cm in length,4 cm in width and 2 cm in depth.The prostate has posterior,anterior and lateral surfaces and a narrowed apex inferiorly and a broad base superiorly.
This gland is contiguous with the bladder base.







Structure:
The prostate contains 70% glandular elements and 30% fibromuscular stroma.The stroma is in continuity with the capsule.The urethra runs thropugh the length of the prostate and is close to the anterior surface of the prostate.The posterior urethra has a urethral crest which runs in the posterior midline and disappears at the striated sphincter.The urethral crest widens and forms verumontanum from which the utricle peeps.To either side of the utricle ejaculatory ducts open carrying semen in the urinary path during ejaculation.At the either side of the crest there are prostatic sinuses into which all the glandular elements of the prostate drain.At the midpoint the prostate bends at approxoimately 35 °.In the proximal part before the bend the circular smooth muscles form an involuntary smooth muscle sphincter.
Small periurethral gland enclosed in the longitudinal fibres of the prostate can grow sometimes in old age and constitute to the bulk of the prostatomegaly(they constitute otherwise only 1 % of the prostate bulk).





Clinically the prostate is talked of having two lateral lobes felt on digital rectal examination(DRE).And one median lobe which protrudes into the bladder causing urinary difficulty.But embryologicallY it contains central zone:surrounding the ejaculatory ducts(25% of the prostate bulk).The transition zone at the angle of preprostatic and prostatic urethra accounting for 5-15% of glandular tissue.
Peripheral zone accounts for 70% glandular tissue and covers the posterior and lateral aspects of the gland.Seventy % of prostate cancers arise in this gland.This zone is also the zone commonly affected by chronic prostatitis.
1/3 rd of the prostate is made by fibromuscular stroma ;it is in continuity with the prostatic capsule,anterior visceral fascia.The cancer rarely invades this region.










ZONAL ANATOMY OF THE PROSTATE
Functions of the prostate:
1)Secretes seminal fluid which carries sperm.This fluid nourishes the sperms.
2)During orgasm, prostate muscles contract and propel ejaculate out of the penis




Risk Factors for BPH
Age – increases with age
Hormones – androgen donot directly cause BPH; but there is imbalance(maintained levels) in intra-prostatic levels of dihydrotestosterone as well as androgen receptor as man ages inspite of peripheral androgen level decrease. The role of oestrogen although was postulated to be the cause of prostatic growth remains still unclear.
Familial – strong relationship found.The hazard -function ratio between first degree male relatives of the BPH and their relatives as controls was 4.2(95% confidence interval).About 50% of the men who undergo prostatectomy at less than 60 years of the age do show some evidence of heritable reason.
Higher socioeconomic status
Sexual activity:Ekman had suggested that the fibromuscular stroma increase as a result of sexual activity.Some people have found that there 40% reduction in the risk of prostatectomy in widowed versus single men.
Metabolic syndrome:Hypertension,obseity,smoking,altered lipid(cholesterol) levels,hyper-uricemia and prostatic enlargement are seen to go hands in hands.


Ref: BPH. Chapple CR. Blackwell Science Publication: 2003: 3-9

Pathophysiology of the Benign Prostatic nlargement:
Microscopically:Nodular prostatic hyperplasia consists of nodules of glands and intervening stroma. (Mostly glands).The glands variably sized, with larger glands have more prominent papillary infoldings.
Changes in Prostate
 Increase in stromal cells and smooth muscle cells
 Contraction of smooth muscle cells
 Contraction of prostatic capsule
Changes in the bladder
 Detrusor instability(can be obstruction related or De-Novo)
 Bladder neck smooth muscle contraction /Urethral compression
 Bladder hypertrophy-Thickness of the bladder wall increase-Good parameter in Ultrasonography to see whether prostatioc enlargement is causing locoregional imbalance.
 Trabeculation of the bladder /Diverticula formation- because of constant increase in bladder pressure for ensuring emptying of the bladder
 Hydroureter/Hydronephrosis: Back pressure changes when there is detrusor muscle failure and changes of chronic retention.







Symptoms of prostatomegaly:

There can be obstructive symptoms like weak stream,interupted stream,hesitancy and sense of incmplete evacuation.There can be irritative symptoms like frequency,nocturia(getting up in the night for passing urine),urgency and urge incontinence.There can be an element of Urinary tract infection like burning of urination,fever and perineal /suprapubic pain.Some people end up in having complications like acute urinary retention(they cannot pass urine),bleeding(sometimes can be life-threatening),stone formation or renal (kidney) failure.There are sometimes sequels of BPH like developing hernia.



Evaluation:
 History and focused physical exam to include DRE and neurologic exam(Must:Famous Dictum:Put your finger in it otherwise you will have to put your foot in it).







This cartoon comes from a website maintained by survivors of prostate cancer. They tell in it how the DRE is so feared by men that many refuse to have it done, as the risk of their lives. They are meant to inject humor in lives of prostate cancer .

 Validated symptom questionnaire.(Photoraphs showing it)






 Urinalysis to exclude UTI and hematuria.
 PSA for those with 10 year life expectancy or for whom the diagnosis of prostate cancer may affect their management.
 Urine cytology in patients with:
 Predominance of irritative voiding symptoms.
 Smoking history
 Flow rate and post-void residual:Not necessary before medical therapy but should be considered in those undergoing invasive therapy or those with neurologic conditions.Generally patient with flow rate more than 12 ml/sec tend to be in unobtrsucted range.
 Urodynamic studies:In patients who are young,more of irritative symptoms and urine flow more than 12 m/sec,presence of neurological disorders etc
 IVP: Especially in upper tract changes.But now-a-days it has been noticed that the IVP is really not necessary and changes the management in only 1-3 % cases.
 Rectal ultrasound:This is usually done if DRE finds some nodule or PSA is high so that abnormal zones can be noted and ultrasound guided biopsy can be done.It is also done in our centres before surgery as depicts true size of the gland so we can mentally be prepared before doing LASER surgery on the patient.
 Renal function tests:In case of renal function derangement the chance of complications are high almost to the tune of 20-25%
Management:

 Watchful waiting( No medications):“is the preferred management technique in patients with mild symptoms and minimal bother”
Following advice is given to the patient with watchful waiting:

A. Decrease caffeine, alcohol and fluid intake.






B. Avoid bladder irritants to include dairy products, artificial sweeteners, carbonated beverages
C. Limit nighttime fluid consumption
 Medical Management:
Medical therapies are not as efficacious as surgical therapies but may provide adequate symptoms relief with fewer and less serious associated adverse events.
 (A) a- blockers :
A. Mechanism Of The Action – Reduces muscle tone & relieves outlet obstruction. Drugs – Prazosin , Doxazosin , Alfuzosin,Terazosin , Tamsulosin
(B) Androgen Suppression :
 Mechansim of action – Blocks DHT & reduces growth
 Drugs – Finasteride and Dutasteride(5 a-reductase inhibitor)
C.Saw Palmetto (Serenoa repens, Sabal serrulata)
National Center for Complementary and Alternative Medicine (NCCAM) says “no role for the treatment of BPH with Saw Palmetto”
AUA concurs:Alpha blocker therapy is appropriate and effective treatment for patients with lower urinary tract symptoms due to BPH
Theory of efficacy is based on the thought that symptoms are caused by an alpha adrenergic contraction of prostatic smooth muscle resulting in bladder outlet obstruction.
a- blockers like doxazosin and terazosin have similar affinity for all three subtypes of alpha receptors.For specific action for relieving smooth muscle sphincteric tone,a1a and a1d blocking is required



Alpha receptor(1a and 1 d location in the trigone)


Blocking of a1b can lead to vasodilatation and Postural Hypotension (prazosin)
Tamsulosin is the most potent a1 agonist available but can causeasthenia,dizziness,rhinitis and abnormal ejaculation.(2%,5%,3% and 11%)respectively.
Alfuzosin has been called as uroselective agent and causes less of dizziness and ejaclatory dysfunction.
(5 a-reductase inhibitor):Dutasteride,Finasteride: Agents are effective and appropriate treatment for patients with lower urinary tract symptoms and demonstrable enlargement of the prostate.
Indications:
oAverage prostate size is 30 cc’s. Original studies showed benefit only in men with prostate sizes greater than 50 cc’s.
oLess effective for relief of BPH symptoms than alpha blockers
Adverse events include
 Decreased libido,Worsened sexual function
 Breast enlargement and tenderness
o Reduces risk of urinary retention by 3%/year.
o PSA must be doubled if screening for prostate cancer(as it reduces PSA by 50% )
o They also prevent hematuria secondary to BPH and reduce the need of surgery(70%)
 Surgical management:





Open simple prostatectomy
TURP
Laser prostatectomy(green light laser PVP,Holmiumand Thulium)
Patients may select surgical treatment as initial therapy if moderate or severe bother is present.
Patients who have developed complications of BPH (i.e urinary retention, renal insufficiency, recurrent UTI) are best treated surgically.
Transurethral resection of prostate (TURP)
1)Gold standard
2)Surgical procedure requiring spinal or general anesthesia
3)Resectoscope inserted through urethra
4)Gland removed in small chips by electrical cutting loop(electrocautery)
5)Inpatient hospitalization required(The pateint may need irrigation to flush out clot in the bladder through the catheter for 1-2 days and catheter removal is usually done after 3-5 days)
 Adverse events
hospital stay(3-5 days)
TUR syndrome (acute hyponatremia from free water absorption occurs in 2-3 % patients)
Risk of incontinence 1%
Decline in erectile function equivalent to watchful waiting
65% of retrograde ejaculation
Greater than 5% risk of:
1)Irritative voiding symptoms
2)Bladder neck contracture
3)UTI
4)Hematuria(the risk of hematuria can be upto 30% sometimes needing blood transfusion)
Dr Ramayya's Urology and Nephrology Institute´s Experience about LASER prostatectomy and review of literature for backing use of Thuium LASER as the LASER of choice in Benign Prostatic Hyperplasia
Traditionally, the gold standard for treatment of BPH (Benign prostatic Hyperplasia) has been the Monopolar Electrocautery based Trans-Urethral Resection of the Prostate (TURP).



TURP is fraught with complications like bleeding during procedure (30%). This results in the inability of the Surgeon to complete the procedure (Residual Prostate) especially in large glands, post operative clot retention, strictures in the urethra and bladder neck and occasionally the TUR syndrome( a cerebero vascular stroke like condition due to hyponatremia).



TURP usually considered to be the to be the Gold Standard because of the durable cavity it creates in a minimally invasive manner becomes a very unsatisfactory procedure in most hands for prostate gland volumes above 40 cc .
The new generation LASER (KTP, Holmium, Thulium Continuous Wave) technology has paved the way forward for a safe and bloodless prostatectomy which is independent of the prostate volume.
The advantages of Laser Therapy over traditional TURP include a virtually bloodless procedure for all gland sizes, shorter hospital stay, less incidence of strictures and early return to activity. As the Laser Energy is delivered in a precise manner without any penetration there is no deep charring of the surrounding tissues and delayed necrosis blood vessels resulting in less incidence of scarring at the bladder neck and delayed haematuria. The procedure can be carried out with smaller caliber instruments resulting in fewer urethral strictures. As the Laser, Plasma Seals the blood vessels there is virtually no bleeding during the procedure. As Normal Saline (0.9%) is used during the procedure TUR Syndrome is virtually unknown


There are several techniques for laser prostatectomy that continue to evolve. The main competing techniques are currently the Holmium Laser Enucleation of the Prostate (HOLEP) and the KTP (Green Light) and Revolix (Thulium Continuous Wave) Laser enucleation, vapo-resection or vaporization of the prostate.
Broadly all the three energy sources (KTP, Holmium, Thulium Continuous Wave) have similar benefits, subtle differences between each, makes the Revolix Continuous Wave Thulium Laser the most attractive option.
The KTP (Green Light) Laser can only be absorbed by hemoglobin. Hence for fibrous glands it is less effective. Secondly once the vaporization has taken place, the energy is not transmitted to the deeper areas of a large gland as the vaporized tissue, devoid of blood supply acts like a barrier, hence it is ineffective for large glands. It only has a side firing fiber making it impossible to enucleate. Finally the fiber cost is prohibitive as it has to be changed for every patient.




The Holmium Laser is absorbed by the water molecule and hence can be used for all sizes and types of prostate glands. The main disadvantage of Holmium is that it is pulsed wave (hence an effective tool for stone disintegration). Pulsed wave dissects the tissue instead of cutting it cleanly and cannot vaporize. Hence it has limitation. It cannot vaporize the prostate tissue or cut it cleanly because of the pulsed nature of the technology. During the procedure a web like blanched appearance is evident hence making it on occasions, difficult to identify the correct plane during enucleation. Secondly while operating in the apical area the energy can be transmitted in different directions resulting in higher incidence of post operative sphincter weakness. Therefore Holmium Laser while being an effective stone laser, has limitations when it comes to the Prostate Gland as it can only enucleate the gland and not vaporize. Hence a morcellator is a must. Secondly as finding the correct plane during enucleation requires experience, the learning curve is very steep.
The Revolix (Thulium Continuous Wave Laser) is an advance over Holmium Laser in that; it is continuous wave (CW) as opposed to the pulsed wave of the Holmium. The CW technology results in clean cutting and effective vaporization.


It retains its ability to be absorbed in the water molecule making it effective for all types of glands including the fibrous gland. Revolix CW Laser can Enucleate (ROLEP, RevOlix Laser Enucleation of Prostate), Vaporize and also Vapo-Resect making it the most versatile Laser in the market for Laser prostatectomy. The clean cutting makes identification of the planes easier with accurate delivery of the energy due to a stable fiber (no vibrations like the Holmium) making the learning curve far less steep.
As it can vaporize as effectively as the KTP it can be used on patients who are unable to stop anticoagulants.
Both Holmium and Thulium CW Laser fibers are reusable and the fiber cost per patient is not more than Rs 1500 (One thousand Five Hundred)





Scientific Evidence
(TURP vs LASER)
A prospective study was conducted in Capital Medical University, Beijing, China by Xia et al in year 2009 comparing TURP and Thulium LASER prostatectomy. They randomized 100 consecutive patients to receive either a Transurethral Resection of Prostate (TURP) (n = 48) or Thulium Laser Prostatectomy (TmLRP) (n = 52). Pre-operative and peri-operative parameters at 1-, 6-, and 12-months follow-up were also evaluated.
TmLRP was significantly superior to TURP in terms of catheterization time (45.7 ± 25.8 h vs. 87.4 ± 33.8 h, P < 0.0001), hospital stay (115.1 ± 25.5 h vs. 161.1 ± 33.8 h, P < 0.0001), and drop in hemoglobin (0.92 ± 0.82 g/dl vs. 1.46 ± 0.65 g/dl, P < 0.001), whereas it required equivalent time to perform (46.3 ± 16.2 vs. 50.4 ± 20.7 min, P > 0.05).
TmLRP and TURP resulted in a significant improvement from baseline in terms of subjective symptoms scoring and urodynamic finding. TmLR was found to be is an almost bloodless procedure with high efficacy and little peri-operative morbidity.




(HOLMIUMvsTHULIUM)

One head to head trial between Holmium Laser and Thulium Laser in BPH patients was carried out in the same Capital Medical University, Beijing, China by Shao et al in 2009. Ninety-eight BPH patients were divided into 2 groups and underwent Transurethral Enucleation of the Prostate with Holmium Laser (Ho group) and Thulium Laser (Th group) respectively. No statistically significant differences were noted between the 2 groups in age and preoperative prostate volume, IPSS, PVR and Qmax (P > 0.05). The mean operation time was shorter in the Th group ([84.6 +/- 10.2] min) than in the Ho group ([70.5 +/- 7.5] min) (P = 0.032); blood loss was less in the former ([126.5 +/- 14.6] ml) than in the latter ([176.5 +/- 14.1] ml) (P = 0.071), with no blood transfusion necessitated; and the mean times of catheter indwelling were 2.4 d and 2.5 d respectively.
Preliminary results as shown in the above study clearly indicates that the CW Thulium Laser is superior to Holmium Laser .





Our experience:

We use 70 W CW Thulium Revolix LASER with Richard Wolf 24 F Continuous Flow Resectoscope and a Richard Wolf Morcellator .
We have treated 300 patients with this technology (age ranging from 48 years to 105 years) and the gland volumes ranging from (10 cc to 210 cc). Many patients were referred because they were high risk from cardiological point of view and so risky for conventional TURP surgery. The catheter is usually removed on the next day. No patient has yet required blood transfusion.
The glands are either enucleated and morcellated or vaporized depending upon the ability to stop the anticoagulants or not.
Non irrigating Foleys 18 F catheter is placed postoperatively with mild traction on occasions. . 8 patients required re-catheterization for retention but it was successfully removed after a period of 3 days. Three patients had stress incontinence but it improved with time and medical management. There were eight patients in the series in which anticoagulation could not be stopped




The Uroflowmetry parameters, AUA score improved significantly in post-operative period and it maintained on long term follow-up also.
Summary:

The advent of modern laser technology continues to offer a serious threat to the current gold standards for treating BPH, viz. TURP/Open prostatectomy. In a randomized trial comparing TURP with HoLEP, Tan et al. demonstrated that HoLEP is superior to TURP in improving urodynamic bladder obstruction along with shorter catheterization time and decreased blood loss. In a recent randomized trial, HoLEP showed better outcomes as compared to open prostatectomy for adenomas larger than 100 g over a long-term follow-up of five years.
However, the learning curve for HoLEP is steep, which has prevented many urologists from accepting this technique.
The Thulium CW LASER is an advance over the Holmium technology. It has excellent cutting and vaporization properties making it very versatile for Vaporization, enucleation and vapo-resection. Hence it can be used for all gland sizes and on patients with anticoagulants which cannot be stopped.

As the fiber is without vibrations, it gives precise cut so in our opinion has edge over Holmium in terms of enucleation (Shao et al study shows the same).
Many Expeienced Holmium LASER Resectionists (enucleationists?) keep three way catheter and give traction. The incidence of immediate postoperative of incontinence is also very high ( through personal correspondence) unlike our series which shows that the CW Thulium Technology is the best, the present Laser Generation has to offer.
In our opinion Thulium CW LASER Protatectomy is the New Gold Standard for prostatectomy and this technology is the one to be adopted by Urologists..
Inspite of better technology it is saddening that there are still a very few centres in India( a population of 1 billion) using LASER rechnology as depicted in Figure





F.A. Q.s about Thulium LASER prostatectomy:

1)What is the recovery time?Is surgery painful?
The patient is undertaken for surgery under spinal anaesthesia so totally unaware about the procedure but he can at the same ime converse with the surgeon and anaesthetist and watch the video of the surgery.
Post-operative he may have burning in urine and bvladder spasms for which usually medications are given.The patient recovers the next day.

2)How long the catheter will be kept?
The common question .The catheter is usually kept for one day ;removed the next day(unlike TURP/open surgery where it is kept for longer)

3)How long will the improvement takje place?
The improvement is immediate but the total improvement may take 30 days(to recover from obstruction related detrusor dysfunction).There is also small risk of incontinence (1%) which improves with time or patient may have to resort to Kegels exercise for the same.
4)Any problem will be encountered at home after discharge?
Usually the post-operative recovery is smooth but few patients may continue to have burning micturition for 1 week or so;for which usually medications are prescribed.
5)How soon I can start sex life?
Sex can be started after 10 days(there are no fixed protocoals/studies).But we restrict them for 10 days; logically because sexual activity increase pelvic blood flow so the chance of bleeding(especially if urethra is also cut during surgery).But there are no studies in this regard.As LASER chars the tissue the bleeding anyway is remote.

6)The most common question I encounter especially from the better half of the patient is what diet I should put the patient on??(If patient doesnot opt for surgery)
The diets role in prevention of progression is unclear.
But urinary irritants-tea,coffee,alcohol can be avoided.(Espcially Beer)As BPH as we have already mentioned in pathophysiology is complex of metabolic syndrome-restrainst of refined carbohydrates(sugar,flour),fatty and oily stuff(unsaturated fatty acids are better),dairy products are to be avoided.
Grains,Fruits and vegetables should be bulk of the diet.
Tomotos(contains lycopene),Garlic and onion(contain quercetin,allicin),lettuces,spinach,carrots,asparagus may provide lots of anti-oxidants and help the cancer fighting abilities of the patient.

Vasectomy: General Information

Vasectomy

It is a procedure where the vas deferens of a man is severed under Local/sedative anaestheisa so as to block passage of the sperms in the semen for the purpose of contraception.


History:

The term vas deferens was coined by Berengarius (1470- 1530). In latin language, vas means vessel and deferre means 'to carry down'.

Vasectomy is a historical, social, philosophic, medical, demographic, and legal phenomenon. There has been constant attempts at renewing the techniques for simplicity and better outcomes.There are lot of misconceptions, false beliefs, and erroneous indications.

Early Years Then in 1830, Sir Ashley Cooper's found that when the blood vessels of a dog's testicle were tied, no issues followed coitus. This was the first step towards development of a surgical procedure for birth control in men called vasectomy. The dog however retained its ability to produce sperms even after 6 years of the surgery.
The first use of vasectomy (1899) was on a 19 year male who had complained of excessive masturbation. The surgery was carried out by a physician by name Harry Sharp. (?Logistics behind the surgery)
Between 1904 and 1907, vasectomy was used to reduce the chances of infection of the epididymis following prostate surgery.
The infamous case where a patient murdered a surgeon, for castration as birth control measure, prompted surgeons to look for another alternative for castration and very soon, vasectomy began to assume an important role.
The vasectomy became so fashionable that it was made compulsory of any confirmed idiot, rapist or a criminal. This led to the flourishment of the concept of eugenics where individuals who were considered as being nuisance to the society were vasectomised so ensure that the future generations were healthy
???


Vasectomy in India:
The 1st vasectomy program on a national scale was launched in 1954 in India. In 1976, a huge government campaign for sterilization was launched and was responsible for the sterilization of millions of Indian couples. Health Ministry had then to face a lot of critisism for carrying out forced vasectomies of men and sterilization of women as a part of the initiative to control population

Indications:
• Contraception
• There are controversial indications for excessive masturbation and for social reasons as explained earlier.

RISKS :
A relationship between vasectomy and increased risk of prostate cancer was postulated (relative risk of 1.6) based on two large cohort stdies.The magnitude of the relative risk is small enough to potentially be explained by the reason those patients who undergo vasectomy are usually people with more health awareness.So these people are more like to undergo prostate cancer screening than the general public.
Myths and misconceptions:







1. Vasectomised people don’t ejaculate:wrong.
More than 95 % of the ejaculate comes from prostate and the seminal vesicles and only 3 % is contributed by the testes so the ejaculate remains the same whether the patient gets vasectomised or not.




2.Men become less masculine.Testosterone continues to be produced even after vasectomy.
Benefits:
• Apart from contraception men are found to increased sexual quality of life probably because of decreased insecurity of making the partner pregnant.
Procedure
Usually done in an outpatient setting, a traditional vasectomy involves numbing (local anesthetic) of the scrotum after which small incisions are made on the hemiscrotum , allowing a surgeon to gain access to the vas deferens. The "vas" is cut and sealed by tying, stitching, cauterization (burning), double folding onto itself or burying in the scrotal fascia.







Modifications:

1. The No-Scalpel method:Dr Shunqiang developed the Non Scalpel Vasectomy popularised as NSV in 1974.It has less complication rate: pain,early recovery,no scar etc.Over 15 million people have undergone NSV since 1974 and the number is increasing.In India this facility is made available by training the Primary Health Centre Officers so that even remotest place also people can undergo NSV.





In this method a sharp hemostat, rather than a scalpel, is used to puncture the scrotum and by rotation bring the vas out.The vas is then stripped and with any of the methods outlined above vasal severence can be carried out.
2. No Needle Non scalpel Vasectomy: Wilson in 2001 initially described this technique .The jet technique of injection obviates use of the needle and has almost 100% efficasy rate.



3. An "open-ended" vasectomy obstructs only one end of the vas deferens, which allows continued pouring of sperm into the scrotum. This method may avoid build-up of pressure in the epididymis. Testicular congestion may also be reduced using this method.
4. The "Vas-Clip" method uses a clip to squeeze shut the flow of sperm. This method may facilitate a better outlook for reversal, as well as reduced pain with probably less success rate.
5. Percuatenous chemical vas occlusion(with silastomers) technique: with reportedly 98% success rate.
Pre-operative counselling:
• This is a permanent method of contraception and reversal is technically challenging procedure.
• Regarding the procedure details and the possibility of hematoma and pain post-operatively.
• Those patients apprehensive can cryopreserve the sperms.
• The slight chance of failure(1:500 short term and 1:4500 long term )should be explained.
• Contraception is not immediate so for first few weeks he may have to use other methods for contraception(may need 6-8 weeks for azoopsermia and about 20-25 ejaculations for the same).
• Patients with unstable relationship with the partner need to give a serous thought regarding the procedure.
• Patient needs to be emphasized that the Vasectomy doesnot protect against STDs and HIV infection.
• Some men are forced by spouses to undergo the surgery in that case the men should be totally convinced and satisfied for the reason.
Why female tubal ligations are more(world wide 5 times more than the vasectomy)This is inspite the mortality rate of vasectomy is 0.1/1 lakh while that of tubal ligation is 4 /1 lakh population)
1. Fear in men regarding the surgery
2. The tubal ligation can be combined with the Cesarean section so it becomes convinient for the couple to go for it after they decide to complete the family.
3. Men forcing the female partner to undergo the procedure(India is a male dominated society)





Complications:


Hematoma,brusing, local pain are some of the uncommon complications (0.1-3%) (rather common with the conventional vasectomy not NSV)





Li S., Goldstein M., Zhu J., et al: The No-Scalpel Vasectomy. J. Urol 1991; 145; 341-4
Sperm granuloma:this can occur in 30% of the people because of the leakage of the sperms from the vasectomy end.Chance of surgical recanalisation is better in sperm granuloma because there is no back pressure blow-outs and secondary epididymal obstruction making reversal difficult.

Post-Vasectomy Pain Syndrome
Post-Vasectomy Pain Syndrome (PVPS), genital pain of varying intensity that may last for a lifetime, (5% and 35% of vasectomized men), The pain can be orchialgia, pain during intercourse, ejaculation, or physical exertion, or tender testes.The pain usually may last for upto 3 months. In cases of persisting pain ,several drugs like NSAIDS,tramadol,gabapantin have been tried with varied success.
In one study, vasectomy reversal was found to be effective for 9 out of 13 patients in reducing the symptoms of refractory chronic post-vasectomy pain. Treatment options for the 4 patients whose pain did not respond to vasectomy reversal were limited. In severe cases castration has been resorted to.
Post-operative care:

1. NSAIDS(pain killers )are given for pain relief.
2. Avoiding exertion and lying supine for 48 hrs is recommended by many doctors.
3. Ice pack application can be resorted to if the pain is refractory.
4. Sexual intercourse should be avoided for 1 week.
5. Patient should document absence of sperms atleast on two occasions to prove that the procedure is successful before he relies totally on vasectomy for contraception.
Vasectomy reversal:

In 2-6% couples vasectomy reversal is undertaken either for desire to have children(change of the partner/change of mind to have more children/unfortunate loss of previous children etc).Some resort to it for unabating post-vasectomy pain syndrome.This surgery is more successful(more than 80% results in our hands) done with microsurgical method.Earlier is the vasal recanalisation better is the chance of success.(Success rate drops after 15 years of the vasectomy)

Urinary Tract Infections:Overview

A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract.
The most common type of UTI is a bladder infection which is also often called cystitis. When the kidney is affected either through ascending or hematogeneous route ( pyelonephritis) UTI can take a serious turn.
Although they cause much annoyance , urinary tract infections can usually be quickly and easily treated with a short course of antibiotics unless it complicated UTI with stone,kidney involvement or generalised factor like decreased immunity-uncontrolled sugars.
•
Epidemiology

UTIs are most common in sexually active women and increase in diabetics and people anatomical malformations of the urinary tract- obstructing stones,stricture or prostatic enlargement.
• An estimated 150 million UTI occur annually on a worldwide basis resulting in 6 billion USD in direct health care expenditures each year. Prevalence of bacteriuria in females is 3.5%.The life time risk of UTI in females is 50 %.
• UTI account for-
 7 million physician’s office visits
 1 million emergency visits
 1 lac hospital admission
 In total: 1.2% total office visits by females,0.6% total office visits by males





Hygiene Issues:
Since bacteria can enter the urinary tract through the urethra (an ascending infection), poor toilet habits (such as wiping back to front for women) can predispose to infection,



Gender aetiology:
Short urethra in females along with proximity to anus predisposes them to UTI. A common cause of UTI is an increase in sexual activity, such as vigorous sexual intercourse with a new partner, although the reason behind this is unclear. The term "honeymoon cystitis" has been applied to this phenomenon
Anatomical factors:
pregnancy in women, prostate enlargement in men ,stricture urethra etc can predispose to UTIs.



Allergy:

Allergies can be a hidden factor in urinary tract infections. For example, allergies to foods can irritate the bladder wall and increase susceptibility to urinary tract infections. Urinary tract infections after sexual intercourse can also be due to an allergy to latex condoms, spermicides, or oral contraceptives.



Immunity Related:
Diabetics,HIV,people convalescing from prolonged illness are prone for infection.
Foreign Body Related:
Indwelling urinary catheters in women and men who are elderly, prostatic stent can be a major cause of UTIs. Any kind of urological intervention also risks the patient for UTI. Scrupulous aseptic techniques may decrease these associated risks.
Use of vaginal diaphragms, pessaries can aggravate the problem and make woman susceptible for UTIs.



While ascending infections are generally the rule for lower urinary tract infections and cystitis, the same may not necessarily be true for upper urinary tract infections like pyelonephritis which may be hematogenous in origin.
The main cause agent is Escherichia coli. Staphylococcus epidermidis is most common in patients using urinary catheters.





Pathophysiology:


The bladder wall is coated with various mannosylated proteins, such as Tamm-Horsfall proteins (THP), which interfere with the binding of bacteria to the uroepithelium. As binding is an important factor in establishing pathogenicity for these organisms, its disruption results in reduced capacity for invasion of the tissues.



The use of urinary catheters, truama,sexual intercourse,surgical intervention or sexual perversion may physically disturb this protective lining allowing bacteria to invade the exposed epithelium.



Decreased immunity(General-HIV,Diabetes etc) or local(elderly population with genitourinary tract atrophy) leads to defective defensive mucosal activity and hence adherence of the bacteria.




PATHOPHYSIOLOGY IN A NUTSHELL

Asymptomatic Bacteriuria: The presence of bacteria in the urinary tract of older adults, without symptoms or associated consequences, is also a well recognized phenomenon which may not require antibiotics.
Many times asymptomatic bacteuria in elderly poplation is left untreated to avoid side-effects of the drugs.
.

Symptoms:
Burning of urine,abdominal pain,flank pain,frequency of urination,lood in the urine,high or low grade fever,pelvic and low ack discomfort especially in females .Perineal pain/post ejaculatory pain,testicular pain are some of the symptoms as per the location of the infection and its severity.

Elderly people may not present with urinary symptoms instead they present with generalised weakness,low grade fever or even hypothermia. Uncontrolled UTI in elderly people can have mortality of 40 %

Diagnosis:
Generally has a spot mid-stream urine sample sent for urinalysis, specifically the presence of nitrites, leukocytes or leukocyte esterase.
If there is a high bacterial load without the presence of leukocytes, it is most likely due to contamination.
The diagnosis of UTI is confirmed by a urine culture.
If the urine culture is negative:
• symptoms of urethritis may point at Chlamydia trachomatis or Neisseria gonorrheae infection.
• symptoms of cystitis may point at interstitial cystitis.
• in men, prostatitis may present with dysuria(Abacterial prostatitis/painful bladder syndrome).
A negative urine test can also suggest the presence of unusual bacteria or viruses causing symptoms of UTI.
In severe infection, characterized by fever, rigors or flank pain, renal function tests are performed. A CT scan may be needed to rule out abscess formation.
Work-up:

However, UTI in young infants and adults must receive some imaging study, typically a Ultrasonography/Micturating cystourethrogram, to ascertain the presence/absence of congenital urinary tract anomalies. Males too must be investigated further.
Specific methods of investigation include x-ray, Nuclear Medicine, MRI and CAT scan technology.
Treatment
Uncomplicated UTIs
Most uncomplicated UTIs can be treated with oral antibiotics such as trimethoprim, cephalosporins, nitrofurantoin, or a fluoroquinolone (e.g., ciprofloxacin or levofloxacin).
The Infectious Disease Society of America recommends SMX/TMP (trimethoprim and sulfamethoxazole) as a first line agent in uncomplicated UTIs rather than fluoroquinolones such as ciprofloxacin. Trimethoprim is one widely used antibiotic for UTIs and is usually taken for seven days. It is often recommended that trimethoprim be taken at night to ensure maximal urinary concentrations to increase its effectiveness.
A three-day treatment of trimethoprim/sulfamethoxazole or ciprofloxacin is usually all that is needed.
Pyelonephritis
If the patient has symptoms consistent with pyelonephritis, intravenous antibiotics may be indicated.
Regimens vary, and include quinolones (e.g. levofloxacin),Cephalosporins,Penicillins etc.The aminoglycosides-netilmycin,amikacin are usually combined with these. These are continued for 48 hours after fever subsides. The patient may then be discharged home on oral antibiotics for a further 5 days.
If the patient makes a poor response to IV antibiotics (marked by persistent fever, worsening renal function),then imaging is indicated to rule out formation of an abscess either within or around the kidney, or the presence of an obstructing lesion such as a stone.
This further needs drainage of the abscess, stenting for obstructed kidney or draining the kidney with percutaneous nephrostomy.
Children
For simple UTIs children often respond well to a three-day course of antibiotics.



Antibiotics used in UTIs





Recurrent UTIs
Patients with recurrent UTIs may need further investigation.
This may include ultrasound scans of the kidneys and bladder or intravenous urography (X-rays of the urological system following intravenous injection of iodinated contrast material).
If there is no response to treatment, other causes like Interstitial cystitis,malakoplakia,carcinoma in situ or Tuberculosis may be the reason.
During cystitis, uropathogenic Escherichia coli challenge innate defenses by invading superficial umbrella cells and rapidly increasing in numbers to form intracellular bacterial communities (IBCs). By working together, bacteria in biofilms build themselves into structures that are more firmly anchored in infected cells and are more resistant to immune system assaults and antibiotic treatments. This is often the cause of recalcitrant chronic Urinary Tract Infections.
Prevention
The following are measures that studies suggest may reduce the incidence of urinary tract infections. These may be appropriate for people, especially women, with recurrent infections:
• Do not delay urination when it is necessary(Infrequent voidin is common in young women-further it becomes habbit).
• Drinking lots of water may also help.
• Cleaning the urethral meatus (the opening of the urethra) after intercourse and passing urine immediately after intercourse has been shown to help.
• It has been advocated that cranberry juice can decrease the incidence of UTI. A specific type of tannin, called A Type Proanthocyanidin, found only in cranberries and blueberries prevents the adherence of certain pathogens (eg. E. coli) to the epithelium of the urinary bladder.


• The tannins that are found in green tea drunk in a daily dose of around 600mls can provide an excellent and cost effective alternative to cranberry juice in the prevention and prevelance of chronic infection.

• For post-menopausal women, a randomized controlled trial has shown that intravaginal application of topical estrogen cream can prevent recurrent cystitis- which can make vagina and lower genitourinary tract supple, moist and resistant to infections. .


• Often long courses of low-dose antibiotics(suppressive antibiotic course) for 6 -12 months are taken at night to help prevent otherwise unexplained cases of recurring cystitis.This is combined with monthly urine routine examination or culture examination
• Ladies getting infection after sexual intercourse can start post-coital prophylaxis with ciprofloxacin.This method is quite effective.

• Recurrent UTIs can also be treated with self start therapy with 3 day course of antibiotics like fluoroquinolones and getting at the same time dip-slide culture to confirm the culture sensitivity.
• Breastfeeding can reduce the risk of UTIs in infants.



final plan to treat UTI

Kidney stone:Information for common man

1. A kidney stone is a hard mineral and crystalline material formed within the kidney or urinary tract.


2. Kidney stones are a common cause of blood in the urine and often severe pain in the abdomen, flank, or groin. One in every 20 people develops a kidney stone at some point in their life.



3. Kidney stones form when there is a decrease in urine volume (dehydration) or an excess of stone-forming substances in the urine(more calcium, oxalate /uric acid). The most common type of kidney stone contains calcium in combination with either oxalate or phosphate. Other chemical compounds that can form stones in the urinary tract include uric acid and the amino acid cystine.


4. The incidence of kidney stones begins to rise when men reach their 40s, and it continues to climb into their 70s (But no age is bar for kidney stone disease). People who have already had more than one kidney stone are prone to develop more stones. A family history of kidney stones is also a risk factor for the development of kidney stones.
5. While some kidney stones may not produce symptoms (known as "silent" stones), people who have kidney stones often report the sudden onset of excruciating, cramping pain in their low back and/or side, groin, or abdomen. Changes in body position do not relieve this pain. The pain typically waxes and wanes in severity, characteristic of colicky pain. It may be so severe that it is often accompanied by nausea and vomiting. Kidney stones also characteristically cause blood in the urine. If infection is present in the urinary tract along with the stones, there may be fever .





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6. Ultrasound is the most commonly used modality for the screening of the renal stone disease but the final and the most informative modality is the helical CT or IVP(X-Ray with the contrast injection.)




7. Most kidney stones less than 4 mm eventually pass through the urinary tract on their own within 48 hours, with ample fluid intake.



8. Pain medications can be prescribed for symptom relief. Certain stones made up of uric acid can get dissolved with the alkalinizing therapy.
9. There are several factors which influence the ability to pass a stone. These include the size of the person, prior stone passage, prostate enlargement, pregnancy, and the size of the stone. A 4 mm stone has an 80% chance of passage while a 5 mm stone has a 20% chance. Stones larger than 9-10 mm rarely pass on their own and usually require treatment.



10. Some medications have been used to increase the passage rates of kidney stones. (alpha blockers such as tamsulosin.) These drugs may be prescribed some people who have stones that do not rapidly pass through the urinary tract.
11. For kidney stones upto 2 cm a procedure called lithotripsy is often used. In this procedure, shock waves are used to break up a large stone into smaller pieces that can then pass through the urinary system. The Lithotripsy(colloquial language LASER) is a day care procedure with more than 80 % success but may need repeated procedures or stenting simultaneously.


12. Surgical techniques have also been developed to remove kidney stones. This may be done through a small incision in the skin (percutaneous nephrolithotomy) or through an instrument known as an ureteroscope passed through the urethra and bladder up into the ureter.
13. The stone is fragmented with LASER (Holmium LASER) before removal with the endoscope.








14. Open surgery is very rarely performed for renal stone disease because of length of hospitalization and recuperation on the part of the patient.


15. Rather than having to undergo the treatment it is better to avoid kidney stones in the first place.(The National Institutes of Health recommend drinking up to 12 full glasses of water a day, if you've already had a kidney stone.) Water helps to flush away the substances that form stones in the kidneys.
16. Depending on the cause of the kidney stones and an individual's medical history, dietary changes or medications are sometimes recommended to decrease the likelihood of developing further kidney stones. It is particularly helpful, if one has passed a stone, to have it analyzed in a laboratory to determine the precise type of stone so specific prevention measures can be considered.
17. Certain foods are better avoided-red meat,fish,cucmber,tomato.cauliflower,chikoo,amla,berries,brinjal,mushroom,cashew nuts, pumpkin, milk products( in excess). palak, chaulai, black grapes etc.
18. Certain food actually help in preventing the stone disease-coconut water, Kulith dal, Barley, pineapple, bananas, almonds, lemons, Carrots, karela.