STONE DISEASE

Kidney Stone is the most painful and prevalent of urologic disorders. More than a million kidney stone cases are diagnosed each year.

• What is a kidney stone?

stone forms in the kidney when there is an imbalance between certain urinary components -chemicals such as calcium, oxalate and phosphate - that promote crystallization and others that inhibit it.

• What happens under normal conditions?

The urinary tract, or system, consists of the kidneys, ureters, bladder and urethra. The kidneys are two bean-shaped organs below the ribs in the back of the torso (area between ribs and hips). They are responsible for maintaining balance by removing extra water and wastes from the blood and converting it to urine. The kidneys keep a stable balance of salts and other substances in the blood. They also produce hormones that build strong bones and help form red blood cells. Urine is carried by narrow muscular tubes, the ureters, from the kidneys to the bladder, a triangular-shaped reservoir in the lower abdomen. Like a balloon, the bladder walls stretch and expand to store urine and then flatten when urine is emptied through the urethra to outside the body.

• Most common stones contain calcium in combination with oxalate and/or phosphate.

A less common type of stone is caused by infection in the urinary tract. This type of stone is called a struvite or infection stone. Much less common are the pure uric acid stones. Much rarer is the hereditary type of stones called cystine stones. Even more rare are those linked to hereditary disorders.

• Who forms kidney stones?

For unknown reasons, the number of people in the United States with kidney stones has been increasing over the past 20 years. Caucasians are more prone to develop kidney stones than African Americans. Although stones occur more frequently in men, the number of women who get them has been increasing over the past 10 years, causing the ratio to change. Kidney stones strike most typically between the ages of 20 and 40. If a person forms a stone, there is a 50 percent chance they will develop another stone.

• What causes a stone to form?

Scientists do not always know what makes stones form. While certain foods may promote stones in susceptible people, researchers do not believe that eating a specific item will cause stones in people who are not vulnerable. Yet they are confident that factors - such as a family or personal history of kidney stones and other urinary infections or diseases - have a definite connection to this problem. Climate and water intake may also play a role in stone formation.

Stones can also form because of obstruction to urinary passage like in prostate enlargement or stricture disease. Stone formation has also been linked to hyperparathyroidism, an endocrine disorder that results in more calcium in your urine. Susceptibility can also be raised if you are among the 70 percent of people with rare hereditary disorders such as cystinuria or primary hyperoxaluria who develop kidney stones because of excesses of the amino acid, cystine or the oxalate in your urine.

STONE

• Diagnosis is done by x-ray, USG and CT SCAN.
• Treatment -
  Small stone which does not cause pain or infection can be treated with medicine

Majority stone requires active treatment

Modalities -

1. Lithotripsy
2. Surgery - PCNL , URS

Extracorporeal shock wave lithotripsy (ESWL)

• Uses shock waves to break a kidney stone or ureteric stone
• into small pieces that can more easily travel through the urinary tract and pass from the body
• ESWL is usually an outpatient procedure
• The process takes about an hour
• Patient may receive sedatives or local

Procedure

DAY CARE P.C.N.L.

• The patient gets admitted on the same day morning at 7:00 am
• Then the spinal anaesthesia is given during which patient remains fully conscious only two lower limbs are paralysed for about one hour.
• The surgery can be watched by the patient and relative on the monitor. Then patient is shifted from or in about average 55-60 minutes.
• Then patient is mobilised and made ambulatory with catheter and starts taking orally in next 2 hours.
• Same patient takes more of liquids and semisolid diet.
• The nephrostomy tube is removed in 4 hours then the per urethral catheter is removed after 8 hours.
• There is only 1 c.m. scar on the back after whole surgery.

RENAL STONEPCNL PUNCTURE

D J STENTSTONES

DAY CARE U.R.S.

• The patient gets admitted on the same day morning at 7:00 am
• Then the spinal anaesthesia is given during which patient remains fully conscious only two lower limbs are paralysed for about 60 minutes
• The surgery can be watched by the patient and relative on the monitor. Then patient is shifted from operation theatre in about average 55-60 minutes.
• Then patient is mobilised and made ambulatory and starts taking orally in next 2 hours.
• Patient takes more of liquids and semisolid diet.

Making the Right Nutritional Choices

There are a number of nutritional choices that you can make as part of a kidney stone diet. These include:

Drink a lot of fluids. To keep kidneys clean and functioning properly, frequent urination can help filter out substances. The only way to achieve a higher percentage of urination is to drink a lot of fluids. And the drink of choice for a kidney stone diet is water.

Adding plenty of water to your body on a daily basis will help reduce high levels of calcium that your kidney will have to filter. As part of a kidney stone diet, the recommended daily dose of water is approximately 2.5 liters of water. Those that drink this much and more water per day have experienced nearly a 40% decrease in their chances of developing a kidney stone versus those who drink less.

People who have or previously experienced calcium, cystine or uric acid kidney must consume a minimum of between eight and ten glasses of fluids regularly throughout the day and night. To fulfill this amount would mean having a glass with each meal as well as through the evening hours. All you have to do is take a look at your urine to see if you are drinking enough fluids each day. You know you have had enough to drink if it appears pale and almost watery. If it is dark and yellow, it could indicate that you may need to take in more fluids.

There are specific situations with a kidney stone diet where the fluid intake must be increased. These include people who stay physically active, live in warm climates, and/or suffer from exertion and stress.

And it is not only about the quantity of water in a kidney stone diet; it also involves the quality as well. Compared to bottled water, which is softer, tap water tends to be hard - also depending on where you live - and has a much higher level of calcium. People who drink mineral water as part of their kidney stone diet - despite these having calcium and magnesium - have the ability of possibility reducing their risk for calcium and uric acid kidney stones.

To raise citrate levels in the urine, a protector against calcium stones, a half cup of pure lemon juice taken daily is recommended as part of a kidney stone diet versus orange juice which, although it raises citrate levels as well, also increase oxalate levels and does not lower calcium quantities.

Avoid carbonated beverages. Eat food rich in fiber. Found in ingredients, such as rye, wheat, barley and rice, insoluble fiber is known to have phytate, a compound that seems to halt the formation of calcium salt crystals. To learn more about how diet plans, vitamin consumption, fluid and fiber intake make a dramatic difference on changing your body's susceptibility to kidney stones, read a feature article on kidney stones diet.

INFERTILITY

Male Infertility

• Male infertility refers to the inability of a male to make a fertile female pregnant. It is usually due to semen deficiencies.

Causes

• The factors may be pre-testicular, testicular or post-testicular.
• Pre-testicular: Drugs, smoking, alcohol, medications affecting spermatogenesis (spironolactone, chemotherapy).
• Testicular: Age, genetic defects, carcinoma, varicocele, trauma, hydrocele, mumps, idiopathic.
• Post-testicular: These defects include the defects in the genital tract and ejaculation problems.

Treatment

The treatment modalities depend upon the underlying disease and extent of impairment.

Pre-testicular issues can be rectified by medicines.

Testicular based infertility is usually medication resistant.

Post-testicular infertility can be overcome by surgery.

In infertility condition, the female fertility should also be checked.

Prostate Cancer

Prostate Cancer also known as carcinoma of the prostate, is the development of cancer in the prostate, a gland in the male reproductive system.

Adenocarcinoma of the prostate is the clinical term for a cancerous tumor of the prostate gland. It's the most common cancer in men after skin cancer. Prostate cancer often grows very slowly and may not cause significant harm. But some types are more aggressive and can spread quickly without treatment. As prostate cancer grows, it may spread to sac-like structures attached to the prostate (seminal vesicles), to tissues near the prostate, the interior of the gland, and to distant parts of the body (bones, liver, lungs, etc).

Risk Factors -

Growing older is the greatest risk factor for prostate cancer, particularly after age 50.

Family history increases a man's risk: having a father or brother with prostate cancer doubles the risk. African-Americans are at high risk and have the highest rate of prostate cancer in the world.

Diet seems to play a role in the development of prostate cancer, which is much more common in countries where meat and high-fat dairy are mainstays. The reason for this link is unclear.

Early prostate cancer is usually discovered during a routine digital rectal examination (DRE).

Symptoms

• Frequent urination, especially at night
• Inability to urinate, Weak or interrupted urine flow
• Blood in urine or semen
• Nagging pain or stiffness in the back, hips, upper thighs, or pelvis
• Painful ejaculation
• Pain or burning during urination (dysuria)

What is PSA?

PSA (prostate-specific antigen) is a protein produced by the cells of the prostate. Its concentration rises in malignancy. The concentration of PSA in the blood provides an estimate of the risk of having prostate cancer.

Yes, the cancer develops in outer part of prostate which is not removed in surgery of BPH. That's why, PSA estimation is still important once a year.

How is cancer finally confirmed?

Once suspected, a transrectal prostatic biopsy is performed by the urologist. This can be done under ultrasound guidance.The procedure is done under local anesthesia and under an antibiotic cover.

PROSTATECTOMY

What are the chances of survival after radical prostatectomy?

This depends on the severity of the prostate cancer(grade), assessment of completion of procedure by a pathologist and PSA response. A 60-year old man whose specimen shows a moderate-grade, organ-confined cancer has a 97% chance of being alive or dying of other causes in the first 10 years after his radical prostatectomy.

Is additional treatment required after radical prostatectomy? Patients may need radiation or hormone treatment depending upon the location of the residual disease.

What is a radical prostatectomy?

Radical prostatectomy is the surgical removal of the prostate, seminal vesicles, tips of the vas deferens with the aim of eradicating the disease completely when it is still within the prostate.It is the first-line treatment for prostate cancer. Laparoscopy radical proastatectomy or Robotic radical prostatectomy is done nowdays with small incision and better recovery.

What is an LRP?

Laparoscopic Radical Prostatectomy (LRP) is a minimal access method for radical prostatectomy.

LRP removes the prostate, seminal vesicles, ends of the vas deferens, and lymph nodes, if required. Cancer control is the same as in open surgery.

What are the benefits of LRP?Two great advantages besides a small cut, less pain and early recovery.

1. Very little blood loss (usually 200-300 ml).
2. More precise anastomosis. In contrast, the conventional radical prostatectomy is typically associated with a blood loss approaching one liter. Less blood loss reduces the chances of transfusion and intra-operative blood
3. Better and magnified view to preserve the neurovascular bundle to achieve better continence and early return of potency.

PORT PLACEMENT IN RADICALSPECIMEN

How many LRP performed till date?

Till date we have performed more than 200 cases of laparoscopic radical prostatectomy with better results.

We are offering this operation to patients with localized carcinoma prostate and few selected cases of metastatic carcinoma prostate.

Kidney Cancer

Sign & Symptoms

• Blood in the urine (urine slightly rusty to deep red)
• Pain in the side that does not go away
• A lump or mass in the side or the abdomen
• Weight loss
• Fever

Diagnosis

Physical exam: The doctor checks the general signs of health and examines for fever and high blood pressure. The doctor also feels the abdomen and side for any lump.

Urine tests: Urine is checked for blood and other signs of disease.

Blood tests: The lab checks the blood to see how well the kidneys are working. The lab may check the level of several substances, such as Creatinine , urea, etc. High level of Creatinine may reflect that the kidneys are not doing their job.

Ultrasound test: A solid tumor or cyst shows up on a sonogram.

CT scan: The patient may receive an injection of dye which show up the kidneys clearly in the pictures. A CT scan can show a kidney tumor.

The lab may check the level of several substances, such as Creatinine , urea, etc. High level of Creatinine may reflect that the kidneys are not doing their job.

Treatment depends mainly on the stage of disease and the patient's general health and age.

• Radical nephrectomy (open or laparoscopic or Robotic) the entire kidney including the kidney cancer is removed. The operation involves removal of the kidney along with the fat around the kidney. All of this tissue is contained in a leathery layer known as Gerota's fascia. If the kidney cancer is quite large and near the adrenal gland which is adjacent to the kidney, the operation can include removal of the adrenal gland as well.
• Partial Nephrectomy is the surgical removal of a kidney tumor along with a thin rim of normal kidney, with the two aims of curing the cancer and preserving as much normal kidney as possible.

CLIPPED RENAL PEDICLECUT SECTIONSPECIMEN

Bladder Cancer

• Urinary Bladder is a hollow bag located in the pelvis, that collects and stores the urine from kidneys. When the normal body cells multiply, they form an abnormal area of cells, called tumour. Signs & Symptoms
• Blood in urine
• Pain and/or burning during urination (dysuria)
• Frequency, urgency
• These symptoms are non-specific and may be linked with other conditions that are unrelated to cancer. Urinary bladder cancer often causes no symptoms until it reaches an advanced stage. If you experience, any of these symptoms, you must see the doctor immediately.

Investigations

• Physical examination
• Urinalysis
• Biopsy
• Ultrasound
• Urine cytology
• Cystoscopy
• Ct scan

Treatment

• Treatment depends upon the cancer type and stage.
• Most widely used therapies are surgery(TURBT, Laparoscopic or robotic radical cystectomy) radiation therapy, chemotherapy, alone or in combination.
• Immunotherapy(intra vesicle BCG) or biological therapy is used in some patients at stage CIS and T1

BLADDER TUMORRADICAL CYSTECTOMY SPECIMEN

Rare Cases

CASE 1 :

LARGE LEFT ADRENAL MASS

A 25 year old muslim male presented to us with left flank pain and heaviness in left side of abdomen since last 7 months. There was no other associated complaints of headache, palpitation or diaphoresis. On general examination the patient was found to be normal. USG Abdomen showed a well-defined heterogeneously hypoechoic lesion with internal cystic areas of size 15 x11 cm in left suprarenal region appearing separate from left kidney p/o left adrenal mass. CECT abdomen showed a 15 x 11 x 12 cm well defined soft tissue heterogeneously enhancing tumor in left suprarenal region . the lesion shows multiple non enhancing necrotic and cystic areas with foci of calcifications. lesion is supplied by left suprarenal artery suggestive of primary adrenal mass lesion phaeochromocytoma/ganglioneuroma. Blood investigations for Metanephrine and 24 hour urinary metanephrine and VMA were done which came out to be normal. The patient was adequately prepared for Laparoscopic excision. Intraoperatively a big mass was noted in left side of abdomen displacing the left kidney inferiorly almost to the pelvis. The mass was excised without any complications laparoscopically. Post operatively patient is recovering well.

CASE 2 :

A 40-year-old male noticed Left scrotal swelling for 10 days . Patient had no significant medical or surgical history in the past except for appendectomy done 10 years back. Physical examination shows spermatic cord swelling around 3 x 2 x 2 cm , at root of scrotum ,firm in consistency , smooth surface , nontender with no cough impulse ,tranillumination test negative and get above swelling possible with no lymphadenopathy or organomegaly on systemic examination. Urinary cytology showed no malignant cells and culture failed to grow any organisms. Ultrasound scan of scrotum show 3.0 X 2.5 X 2.0 cm size echogenic lesion in Lt spermatic cord with Internal anechoic area 2.0 x 1.7 x 1.5 cm is seen in echogenic lesion possibility of Inflammatory lesion (with abscess formation) in Lt spermatic cord is likely ,possibility of underlying tuberculous lesion should be considered .Colour Doppler shows normal vascularity in testis and epididymis on both sides . Blood counts, lipid profile and other haematological and biochemical investigations were within normal limits. Spermatic cord mass excision and closure was done on 06/12/16 and histological examination lesion showed Non hodgkin's lymphoma ,diffuse large B -cell lymphoma type (activated germinal center type ) scrotal mass. Post operative period was uneventful and patient was discharged.

STRICTURE URETHRA

Urethral stricture is the abnormal narrowing of the urethra(tube that releases urine from the body).

Causes, incidence, and risk factors

• inflammation or scar tissue from surgery, disease, or injury. history of sexually transmitted disease (STD), repeated episodes of urethritis or benign prostatic hyperplasia (BPH). after an injury or trauma to the pelvic region. Any instrument inserted into the urethra.
• Difficulty in urinating
• Urine stream (may develop suddenly or gradually)
• Spraying of urine stream

Investigations

• Urinary flow rate,PVR measurement
• Post-void residual (PVR) Urinalysis,Urine culture
• Tests for Chlamydia and Gonorrhea
• Retrograde urethrogram to confirm diagnosis
• Urethroscopy

Treatment

• The treatment comprises of the placement of a suprapubic catheter, which allows the bladder to drain urine through the abdomen. It may be necessary to reduce acute problems such as urinary retention and infection. Surgical options vary depending on the location and length of the stricture.
• Visual internal urethrotomy may be all that is needed for small stricture
• Open urethroplasty may be performed for long strictures by removing the affected portion or replacing it with another tissue. The results vary depending on the size and location of stricture, prior therapies and the experience of the surgeon. The results of the treatment depend upon the characteristics of the stricture viz. its length, degree of fibres, associated infection, and previous surgeries.

VISUAL INTERNAL URETHROTOMY

URETHROPLASTY

ERECTILE DYSFUNCTION

Overview

• Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for his or his partner's sexual needs. Most men experience this at some point in their lives, usually by the age of 40

Causes

• Diseases such as diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, vascular disease, and neurologic diseaseaccount for about 70 % of ED cases.. Smoking, overweight and avoiding exercise are possible causes of ED.
• surgery (especially radical prostate and bladder surgery for cancer) can causing ED. Injury to the penis, spinal cord, prostate, bladder, or pelvis can lead to ED
• many common medicines like blood pressure drugs, antihistamines, antidepressants, produce ED as a side effect. Stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure cause 10-20 % of ED cases

Diagnosis

Laboratory Tests Several laboratory tests can help diagnose ED. Tests for systemic diseases include blood count, urinalysis, lipid profile, free testosterone and measurements of Creatinine and liver enzymes Psychosocial Examination Psychosocial examination comprising of an interview and a questionnaire reveals psychological factors. Patient's sexual partner may also be interviewed to determine expectations and perceptions during sexual intercourse.

PIPE test is done where erection is achieved by injecting drug to rule out systemic disease

Surgery Implanted devices (known as prostheses) is used to achieve erection in many men with ED.

Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa.

Inflatable implants consist of paired cylinders, which are surgically inserted inside the penis and can be expanded using pressurized fluid. Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis to some extent

Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of technological advances.

Treatment

Most physicians suggest that treatments proceed from least to most invasive

Psychotherapy and behavior modifications in selected patients are considered next if indicated, followed by oral or locally injected drugs, vaccumdevices and surgically implanted devices. In rare cases, surgery involving blood vessels may be considered.

• Psychotherapy Experts often treat psychological ED using techniques that decrease anxiety associated with intercourse. Patient's partner can help with the techniques, which include gradual development of intimacy and stimulation.
• Drug Therapy Drugs for treating ED can be taken orally, injected directly into the penis, or inserted into the urethra from the tip of the penis. Taken an hour before sexual activity.
• Vaccum Devices Mechanical vaccum devices cause erection by creating a partial vacuum, which draws blood into the penis, engorging and expanding it.

Surgery

Implanted devices (known as prostheses) can rest

erection in many men with ED. Possible problems with implants include mechanical breakdown and infection, although mechanical problems have diminished in recent years because of technological advances. Malleable implants usually consist of paired rods, which are inserted surgically into the corpora cavernosa Inflatable implants consist of paired cylinders, which are

surgically inserted inside the penis and can be expanded using pressurized fluid. Tubes connect the cylinders to a fluid reservoir and a pump, which are also surgically implanted. The patient inflates the cylinders by pressing on the small pump, located under the skin in the scrotum. Inflatable implants can expand the length and width of the penis to some extent.