Urology

About Urology

Urology is a part of health care that deals with diseases of the male and female urinary tract (kidneys, ureters, bladder and urethra). It also deals with the male organs that are able to make babies (penis, testes, scrotum, prostate, etc.). Since health problems in these body parts can happen to everyone, urologic health is important.

Urology is known as a surgical specialty. Besides surgery, a urologist is a doctor with wisdom of internal medicine, pediatrics, gynecology and other parts of health care. This is because a urologist encounters a wide range of clinical problems.

UROLOGY SERVICES

  • Can be a large revenue earner because of large number of Urology problems which need Rx by surgery or medications.
  • Commonest problems are “Stone Disease” (kidneys, ureters, bladder, rarely urethra), Prostate enlargement (Benign Prostatic Hyperplasia), Pediatric Urology like abnormal opening of urethra on penis (male children), Stress Incontinence in women etc.
  • Many Urologists are trained to do Renal Transplants : HUGE revenue earner, but having its own problems.
  • Staghorn” calculi of kidneys can cause renal faulure but Can be tackled with pcnl: per cutaneous nephro lithotripsy.
  • Completely “endoscopic” procedure, pt stays overnight
  • Ureteric calculi are treated with endoscope introduced through urinary bladder into ureters and stone is crushed or fragmented using some energy source

ESWL MACHINES

  • Eswl stands for extra corporeal shockwave lithotripsy
  • (This Translates Into: Out of Body Stone Crushing using Shock Waves)
  • What is lithotripsy?
  • Lithotripsy is a noninvasive (the skin is not pierced) procedure used to treat kidney stones that are too large to pass through the urinary tract.
  • Lithotripsy treats kidney stones by sending focused ultrasonic energy or shock waves directly to the stone first located with fluoroscopy (a type of X-ray “movie”) or ultrasound (high frequency sound waves).
  • The shock waves break a large stone into smaller stones that will pass through the urinary system. Lithotripsy allows persons with certain types of stones in the urinary system to avoid an invasive surgical procedure for stone removal.
  • In order to aim the waves, the operator must be able to see the stones under X-ray or ultrasound.
  • Eswl: extra corporeal shockwave lithotripsy
  • No incision but stones are fragmented and pass out in urine, repeated sessions may be required
  • Limitations of eswl : large stones, larger than 1.5 cm

PROSTATE SURGERY

  • Also completely endoscopic
  • Very common in elderly males
  • Can be treated with medicines, but some patients require surgery
  • Different types of energy sources used
  • Laser is very popular for this surgery
  • Holmium and thulium (green light) are the two most popular lasrers
  • Both quite expensive
  • Urologists have their own choice of laser

CANCER SURGERY AND OTHER OPERATIONS DONE BY UROLOGIST

  • Apart from benign diseases (discussed) , urologists also treat malignant diseases like renal cancer, prostate cancer, bladder cancer, and cancer of testis and penis.
  • Prostate cancer is commoner in older men.
  • All these cancers require a combination of surgery, chemotherapy and radiation oncology.
  • Adrenal tumours like pheochromocytoma are also treated by them.
    RENAL CANCERSADRENAL GLANDS ON KIDNEYS

EQUIPMENT REQUIREMENTS OF UROLOGY DEPT

  • Complete set of operating endoscopes including very delicate and expensive ureteroscopes
  • Lasers (either holmium or gereenlight, depending upon preference of urologist)
  • If laser available: laser technician has to be employed
  • Many senior urologists who are trained in renal transplant will only join if there is a renal transplant unit
  • Some urologists practice andrology, so will have some additional requirements.
  • Some are into urethral surgery

RENAL TRANSPLANTS : HISTORY AND BASICS

  • One of the earliest mentions about the real possibility of a kidney transplant was by American medical researcher Simon Flexner, who declared in a reading of his paper on "Tendencies in Pathology" in the University of Chicago in 1907 that it would be possible in the then-future for diseased human organs substitution for healthy ones by surgery, including arteries, stomach, kidneys and heart.
  • The kidney was the easiest organ to transplant: Tissue typing was simple, the organ was relatively easy to remove and implant, live donors could be used without difficulty, and in the event of failure, kidney dialysis was available from the 1940s.
  • The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause.
  • Diabetes is the most common known cause of kidney transplantation, accounting for approximately 25% of total transplants in USA
  • The majority of renal transplant recipients are on dialysis (peritoneal dialysis or hemodialysis) at the time of transplantation. However, individuals with chronic kidney disease who have a living donor available may undergo pre-emptive transplantation before dialysis is needed. If a patient is put on the waiting list for a deceased donor transplant early enough, they may also be transplanted pre-dialysis.
  • For the transplant recipient: HUGE change in life style from dialysis to normal life, with few precautions, and life long medication to suppress rejection (Immuno-suppressants).

CONTRA-INDICATIONS FOR RENAL TRANSPLANT

  • CONTRA-INDICATIONS TO RECEIVE A RENAL TRANSPLANT :
  • Significant cardiovascular disease, incurable terminal infectious diseases and cancer are often transplant exclusion criteria.
  • In addition, candidates are typically screened to determine if they will be compliant with their medications, which is essential for survival of the transplant.
  • People with mental illness and/or significant on-going substance abuse issues may be excluded.
  • HIV was at one point considered to be a complete contraindication to transplantation. There was fear that immunosuppressing someone with a depleted immune system would result in the progression of the disease. However, some research seem to suggest that immunosuppressive drugs and antiretrovirals may work synergistically to help both HIV viral loads/CD4 cell counts and prevent active rejection.

SOURCE OF KIDNEYS AND TRANSPLANT NUMBERS IN INDIA

  • Since medication to prevent rejection is so effective, donors do not need to be similar to their recipient.
  • In India: majority of donors are living (related and unrelated).
  • The living kidney transplantation program in India has evolved in the past 45 years and is currently the second largest program in numbers (after the USA).
  • It is estimated that almost 220,000 people require kidney transplantation in India. Against this, currently, approximately 7500 kidney transplantations are performed at 250 kidney transplant centers in India.
  • Of these, 90% come from living donors and 10% from deceased donors.

ISSUES WITH KIDNEY DONORS IN INDIA

  • There are currently no long-term studies looking at the safety of the kidney donor's health in India. The rising incidence of lifestyle diseases such as diabetes and hypertension makes long-term follow-up of kidney donors in India an urgent consideration.
  • One study has clearly shown that donors who develop diabetes or hypertension post-donation have a 4-fold higher risk of proteinuria and a >2-fold higher risk of end-stage renal disease (ESRD).
  • FASTER RECOVERY FOR DONORS POST-DONATION:
  • There has been a gradual shift toward more transplant centers offering laparoscopic donor nephrectomy with a few also offering robotic kidney transplantation.
  • Lots of ignorance and myths surrounding kidney donation in the public.

ISSUE OF ORGAN TRADE

  • In the developing world some people sell their organs illegally. Such people are often in grave poverty, or are exploited by salespersons. The people who travel to make use of these kidneys are often known as 'transplant tourists'.
  • These patients may have increased complications owing to poor infection control and lower medical and surgical standards.
  • Many kidney rackets are being exposed every day, and reputed hospitals are involved: with or without the knowledge of the higher authorities.
  • Indian Govt has many regulatory mechanisms in place, but people still manage to find loopholes.

DECEASED DONORS FOR KIDNEYS (AND OTHER ORGANS)

  • Deceased donors can be divided into two groups:
  • Brain Dead Donors (BDD) and Donation after Cardiac Death (DCD)
  • Although brain-dead (or 'heart beating') donors are considered dead, the donor's heart continues to pump and maintain the circulation.
  • This makes it possible for surgeons to start operating while the organs are still being perfused using a machine.
  • Donation after Cardiac Death' donors are patients who do not meet the brain-dead criteria but, due to the unlikely chance of recovery, have elected via a living will or through family to have support withdrawn. In this procedure, Mechanical Ventilation is discontinued. After a time of death has been pronounced, the patient is rushed to the operating room where the organs are recovered.

ISSUES OF COMPATIBILITY

  • In general, the donor and recipient should be ABO and Rh blood group compatible, and HLA compatible. If a potential living donor is incompatible with his/her recipient, the donor could be “exchanged” for a compatible kidney.
  • HLA: Human Leucocyte Antigen
  • Kidney exchange, also known as “kidney paired donation” or "chains" have recently gained popularity.
  • Exchanges and chains are a novel approach to expand the living donor pool. In February 2012, this novel approach to expand the living donor pool resulted in the largest chain in the world, involving 60 participants.
  • In 2014 the record for the largest chain was broken again by a swap involving 70 participants.

SURGICAL ISSUES

  • Recipient kidneys are not removed as it was shown to Increase surgical morbidity.
  • New transplanted kidney is placed in an iliac fossa
  • Two teams of surgeons are engaged: donor team and Recipient team. Both work simultaneously.
  • Donor kidney is “harvested” using laparoscopy or robotic Techniques (aim is minimum trauma and fastest recovery For donor).
  • Kidney is harvested with renal artery, renal vein And large segment of ureter also
  • Usually done by urologist & general surgeon

SURGERY CONTINUED

  • While donor team is removing kidney (nephrectomy), the recipient team is Preparing the “bed” for new kidney in the recipient’s abdomen
  • Timing is very important as a bed has to be ready when donor kidney is Brought into the ot
  • Both teams work in adjoining ots
  • Kidney is transported on a bed of ice (often by nephrologist)
  • At recipient site (always open surgery, never laparoscopic)
  • New kidney is placed retro-peritoneally
  • It has to be connected using three major steps:
  • Anastomosis of renal artery (most difficult step, often done by a Vascular or cardiac surgeon)
  • Anastomosis of renal vein
  • Reimplantation of ureter into recipient bladder, but after checking For urine production by new kidney.
  • Urine comes in spurts and can be easily seen

POST OP CARE OF RENAL RECIPIENT

  • Always in a “renal transplant icu” with positive pressure ventilation.
  • Nurses and doctors working there are “dedicated staff”
  • All staff shold be highly trained in managing renal transplant patients
  • Monitor the patient and look for signs of complications like hyperacute graft rejection: occurs within hours, and needs nephrectomy
  • Renal artery thrombosis or stenosis
  • Urine leaks from ureteric anastomoisis
  • Fluid & electrolyte imbalances

CASE STUDY

  • Indian Express 19 August 2016
  • A metropolitan magistrate’s court on Thursday granted bail to five doctors of Dr LH Hiranandani hospital, Powai.
  • The accused, who were arrested in connection with the kidney racket, were granted bail on a surety of Rs 30,000.
  • The court also imposed other conditions including presenting themselves at the police station once a week till the next month. The five will also not be permitted to leave the country without seeking the court’s permission.
  • The doctors were arrested on August 18 for alleged negligence in following regulations governing organ donation. So far, three others, including the intended recipient of the kidney, B J, organ transplant coordinator at the hospital and the donor have been granted bail.
  • Earlier in the day, the Powai police recorded the statement of Sundar Singh, one of the whistleblowers in the kidney racket, which has led to the arrests of 14 persons in the case so far. Singh