She was taken up for PCNL.A total of 4 punctures in different calyces had to be made.The surgery was carried out in 3 sessions.At the end we could give a complete endoscopic and fluoroscopic clearance.
Monday, July 18, 2011
PCNL in a complete staghorn calculus
A 40 year old lady presented to us with flank pain on left side on and off for a period of 6 months.On investigations she was found to have calculus -a complete staghorn variety in the left renal pelvis.
She was taken up for PCNL.A total of 4 punctures in different calyces had to be made.The surgery was carried out in 3 sessions.At the end we could give a complete endoscopic and fluoroscopic clearance.
She was taken up for PCNL.A total of 4 punctures in different calyces had to be made.The surgery was carried out in 3 sessions.At the end we could give a complete endoscopic and fluoroscopic clearance.
Wednesday, July 6, 2011
Interstitial cystitis/Painful bladder syndrome: A review
A 45 year old lady came to us with recurrent complaints of pain while passing urine,suprapubic discomfort,urgency lasting for more than 1 years.She had been investigated extensively and was given antibiotics/bladder spasmolytics/antimuscarinic agents/NSAIDs with no relief.Her all the investigations were normal.She was taken up for cystoscopy which revealed bladder capacity of 250 ml with glomerulations on emptying the bladder.The bladder biopsy was done after a therapeutic distension for 8-10 minutes.The patient was started on amitryptiline,Comfora(sodium pentosan polysulphate 100 mg three times a day)and gabapentin(TRIPLE THERAPY).She had temporary remission after the institution of the therapy and now relatively free of the symptoms.We are planning to repeat the distension after a period of 6 months.
REVIEW OF LITERATURE:
The interstitial cystitis is a chronic condition which comprimses of a constellation of symptoms-bladder pain, suprapubic/pelvic pressure, urgency, dysuria etc. The all above symptoms may occur together or the patient may suffer each one of them in isolation.
This is diagnosis of exclusion and requires a high level of suspicion on the part of the treating urologist. Any patient having unexplained irritative bladder symptoms without relief and the all investigations showing no culprit then we must doubt painful bladder syndrome.
The condition has been seen as debility because its effect on patients quality of life. A Harvard medical scholl guide states that the impact of this condition on the patient can be compared with chronic cancer pain /or renal dialysis.
The International Continence Society (ICS) reserves the diagnosis of IC for patients with “typical cystoscopic and histological features,” without further specifying these. In the absence of clear criteria for “IC,” this chapter will refer to PBS/IC and IC interchangeably, because all but recent literature terms the syndrome “IC.”(Campbells Book of Urology)
National Institute of Diabetes and kidney Diseases(NIDDK) diagnostic criteria:It’s a cystoscopic and histological diagnosis.Cystoscopy should demonstrate glomerulations(with or without Hunners ulcer)-diffuse on distension of bladder.
There are some conditions which must be excluded:-UTI/vaginitis/prostatitis
-Urinary tuberculosis
-Stone disease
-Radiation/cyclophosphamide cystitis
-malignancy
-herpetic affections(less than 3 months duration)
-urethral instrumentation(recent)
-stricture urethra
Urodynamically-the pain should be elicited after filling the bladder for 100-150 ml and the capacity should not be more than 350 ml.There should be any presence of uninhibited bladder contractions.
The typically age of the patient should be more than 18 years and the symptoms should be present for more than 9 months. There should not be a relief on institution of anticholinergics /antibiotics.
A patient who fulfills these criteria can be termed to be a patient of interstitial cystitis.
This condition is more common in women especially menopausal women. Although all the people irrespective of age, socioeconomic status, menopausal status do suffer from this syndrome.
The patient of IC/PBS may have associated illnesses like-allergic conditions,Inflammatory bowel diseases,Fibromyalgia and focal vulvitis etc.
Aetiology:The IC as such is a complex condition with no direct etiological agent to attribute this condition to. Neurological/allergic/autoimmune/stress-psychological conditions have been supposed to be playing a role in these conditions. Presence of MAST cells in the bladder is supposed to be a pathognomonic marker of the disease. The association of mastocytosis, IC and inflammatory bowel disorders is intriguing. The bladder permeability defect due to lack of surface bladder glycosaminoglycans can lead to aggravation of the condition. The treatment now also is aimed at restoring this protective layer of the bladder.
Diagnosis:
The cystoscopic visualization of glomerulations is not a specific for diagnosis. Potassium chloride sensitivity test although not a specific again but can hint to success of pentosan polysulphate.
Management:
1. Behavioural modification: May help in patients having predominant frequency but less pain.
2. Diet: Certain foods can aggravate the condition like banana, cranberries, tea, coffee, alcoholic beverages, ketchups, Mayonnaise, carbonated drinks, junk foods, onion etc..
3.Medications: Antihistaminics to control mast cell proliferations,amitryptiline to fight with neurogenic inflammation,oral pentosan polysulphate to restore the protective layer of the bladder have been used in this condition with variable success rates.In india it is available as Comfora 100 mg three times a day for 3 months and then re-evaluate the patient.The side effects like nausea,diarrhea,rashes and reversible alopecia have been reported.Tachyphylaxis is also reported.
4.Bladder instillation therapies:DMSO – a wood pulp extract is the only agent FDA approved for the instillation.25% or 50% solutions have been used for the instillation.
With its ease of administration, lack of side effects, and dependable symptomatic results, DMSO has been a treatment of choice with many treating doctors. Some people add triamcinolone, 40,000 units of heparin, and sodium bicarbonate for better success.
5. Bladder distension:
Bladder distension stretches the bladder and gives a temporary relief for few months. It is done under general anesthesia. The bladder is distended for 2 minutes with 80 cm of H20 and then deflated again to see the glomerulations. Once it is done a therapeutic distension is done for 8 minutes followed by bladder biopsy for mast cells detection.
6. Radical surgical options are sometimes chosen like subtotal cystectomy with augmentation or ileal diversion with or without cystectomy. The results are somewhat positive. But as the underlying condition of neurogenic inflammation may not go -phantom bladder pain may persist.
REVIEW OF LITERATURE:
The interstitial cystitis is a chronic condition which comprimses of a constellation of symptoms-bladder pain, suprapubic/pelvic pressure, urgency, dysuria etc. The all above symptoms may occur together or the patient may suffer each one of them in isolation.
This is diagnosis of exclusion and requires a high level of suspicion on the part of the treating urologist. Any patient having unexplained irritative bladder symptoms without relief and the all investigations showing no culprit then we must doubt painful bladder syndrome.
The condition has been seen as debility because its effect on patients quality of life. A Harvard medical scholl guide states that the impact of this condition on the patient can be compared with chronic cancer pain /or renal dialysis.
The International Continence Society (ICS) reserves the diagnosis of IC for patients with “typical cystoscopic and histological features,” without further specifying these. In the absence of clear criteria for “IC,” this chapter will refer to PBS/IC and IC interchangeably, because all but recent literature terms the syndrome “IC.”(Campbells Book of Urology)
National Institute of Diabetes and kidney Diseases(NIDDK) diagnostic criteria:It’s a cystoscopic and histological diagnosis.Cystoscopy should demonstrate glomerulations(with or without Hunners ulcer)-diffuse on distension of bladder.
There are some conditions which must be excluded:-UTI/vaginitis/prostatitis
-Urinary tuberculosis
-Stone disease
-Radiation/cyclophosphamide cystitis
-malignancy
-herpetic affections(less than 3 months duration)
-urethral instrumentation(recent)
-stricture urethra
Urodynamically-the pain should be elicited after filling the bladder for 100-150 ml and the capacity should not be more than 350 ml.There should be any presence of uninhibited bladder contractions.
The typically age of the patient should be more than 18 years and the symptoms should be present for more than 9 months. There should not be a relief on institution of anticholinergics /antibiotics.
A patient who fulfills these criteria can be termed to be a patient of interstitial cystitis.
This condition is more common in women especially menopausal women. Although all the people irrespective of age, socioeconomic status, menopausal status do suffer from this syndrome.
The patient of IC/PBS may have associated illnesses like-allergic conditions,Inflammatory bowel diseases,Fibromyalgia and focal vulvitis etc.
Aetiology:The IC as such is a complex condition with no direct etiological agent to attribute this condition to. Neurological/allergic/autoimmune/stress-psychological conditions have been supposed to be playing a role in these conditions. Presence of MAST cells in the bladder is supposed to be a pathognomonic marker of the disease. The association of mastocytosis, IC and inflammatory bowel disorders is intriguing. The bladder permeability defect due to lack of surface bladder glycosaminoglycans can lead to aggravation of the condition. The treatment now also is aimed at restoring this protective layer of the bladder.
Diagnosis:
The cystoscopic visualization of glomerulations is not a specific for diagnosis. Potassium chloride sensitivity test although not a specific again but can hint to success of pentosan polysulphate.
Management:
1. Behavioural modification: May help in patients having predominant frequency but less pain.
2. Diet: Certain foods can aggravate the condition like banana, cranberries, tea, coffee, alcoholic beverages, ketchups, Mayonnaise, carbonated drinks, junk foods, onion etc..
3.Medications: Antihistaminics to control mast cell proliferations,amitryptiline to fight with neurogenic inflammation,oral pentosan polysulphate to restore the protective layer of the bladder have been used in this condition with variable success rates.In india it is available as Comfora 100 mg three times a day for 3 months and then re-evaluate the patient.The side effects like nausea,diarrhea,rashes and reversible alopecia have been reported.Tachyphylaxis is also reported.
4.Bladder instillation therapies:DMSO – a wood pulp extract is the only agent FDA approved for the instillation.25% or 50% solutions have been used for the instillation.
With its ease of administration, lack of side effects, and dependable symptomatic results, DMSO has been a treatment of choice with many treating doctors. Some people add triamcinolone, 40,000 units of heparin, and sodium bicarbonate for better success.
5. Bladder distension:
Bladder distension stretches the bladder and gives a temporary relief for few months. It is done under general anesthesia. The bladder is distended for 2 minutes with 80 cm of H20 and then deflated again to see the glomerulations. Once it is done a therapeutic distension is done for 8 minutes followed by bladder biopsy for mast cells detection.
6. Radical surgical options are sometimes chosen like subtotal cystectomy with augmentation or ileal diversion with or without cystectomy. The results are somewhat positive. But as the underlying condition of neurogenic inflammation may not go -phantom bladder pain may persist.
LASER BLADDER NECK INCISION: SMALL FIBROTIC PROSTATE WITH BLADDER OUTLET OBSTRUCTION
A 60 year old gentleman came with complaints of weak stream,frequency,nocturia over a period of 1 year.He was tried on alpha blockers before but didnot respond.He was a known case of asthma in remission not on any brochodilators.His ultrasound has shown 20 cc prostate with 90 cc post-void residual urine and increased bladder wall thickness(6 mm).
His PSA was 1.77 ng/ml,urine culture was sterile and other hematological and biochemical parameters were normal.His uroflowmetry showed obstructive pattern.He was taken up for LASER BNI surgery.The bladder showed grade 2 trabeculations with high bladder neck.The prostate and the anterior urethra was grossly normal.The Bladder neck incision was carried out with continuous wave Thulium laser ( 2 micron) with 70 w power.The incision was carried out from the level of ureteric orifices till the level of verumontanum reaching to the depths of the capsule.At the end of the procedure the bladder neck region was widely open as seen with stopping the irrigation.The hemostasis was achieved and 18 Fr foleys catheter ( a 2 -way catheter) with no traction and irrigation.The plan is to remove catheter after 24 hours and give him a catheter free trial.
His PSA was 1.77 ng/ml,urine culture was sterile and other hematological and biochemical parameters were normal.His uroflowmetry showed obstructive pattern.He was taken up for LASER BNI surgery.The bladder showed grade 2 trabeculations with high bladder neck.The prostate and the anterior urethra was grossly normal.The Bladder neck incision was carried out with continuous wave Thulium laser ( 2 micron) with 70 w power.The incision was carried out from the level of ureteric orifices till the level of verumontanum reaching to the depths of the capsule.At the end of the procedure the bladder neck region was widely open as seen with stopping the irrigation.The hemostasis was achieved and 18 Fr foleys catheter ( a 2 -way catheter) with no traction and irrigation.The plan is to remove catheter after 24 hours and give him a catheter free trial.
PCNL in complete staghorn calculus
A 45 year old lady came with left flank dull in nature since 6 months.She underwent a battery of tests including ultrasound KUB region and IVP which revealed a complete staghorn calculus on left side.Her other hematological and biochemical work up was essentially normal.She was taken up for PCNL.The patient and the attendants were explained about multiple settings and ESWL adjuvant therapy if need arises.
Today,PCNL was carried out with postero-inferior calyceal approach and around 70% bulk of the stone was cleared.The nephrostomy tube was left in the pelvis.The plan is to second session of PCNL after 48 hours with the same tract and using the flexible nephroscope for access to all calyces.
Today,PCNL was carried out with postero-inferior calyceal approach and around 70% bulk of the stone was cleared.The nephrostomy tube was left in the pelvis.The plan is to second session of PCNL after 48 hours with the same tract and using the flexible nephroscope for access to all calyces.
Tuesday, July 5, 2011
SEMEN BANKING: MUST BEFORE CHEMO/RADIOTHERPY IN YOUNG ADULTS
A 30 year old gentleman came to us with primary infertility.He had a very good educational background and belonged to banking sector.He was found to have severe oligospermia on evaluation.He was a known case of testicular carcinoma -Non seminomatous having undergone adjuvant chemotherapy.He was never counselled about sperm banking before the institution of chemotherapy.
One 1999 survey conducted by the Cleveland Clinic Foundation found that only about 50% of cancer patients receive adequate information about their post-treatment reproductive options, and that only about 25% of men eligible to bank sperm do. Given that the survival rate for testicular cancer is so high, quality of life issues such as family building are relevant to literally millions of cancer survivors like the one in our case.
The patient has just to visit the sperm bank and deposit the semen.The initial semen analyiss is done and then the semen is cropreserved.Even if the patient has undergone orchiectomny initially it is worth visiting the sperm bank and store whatever sperms he has now.With the advances in Assisted Reproductive Technologies and ICSI even a single sperm cell can be utilised for the successive IVF.
What is sperm bankingThe sperms are cryopreserved.With the induction of cooling the metabolic rate of the sperm is brought to a minimum level and they are halted in a state of suspended animation till they are thawed.The cooling and thawing can damage the sperms if done repeatedly but the sperms so obtained doesnot appear to altered genetic material.
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