Urology

Urology - Columbia Asia Hospital, India
The Department of Urology at Columbia Asia Hospitals, offers a wide range of services for urological diseases. The Consultants in the department are highly qualified and experienced in the latest techniques in the field including LASER surgery and minimally invasive techniques that enable a patient to return to their normal activity much quicker as compared to conventional techniques.

The department is supported by lab and diagnostic services such as radiology, pathology, microbiology and other laboratory services. The hospital is equipped with modern facilities and latest equipment to treat all urological disorders. This enables the team to provide comprehensive uro-oncology, reconstructive urology and pediatric urology services. They also provide andrology services like penile implants and male infertility treatment. The urology department offers round the clock emergency services for urinary obstruction, infection, urological trauma and other emergencies.

Treatments and Procedures
  • Female urological procedures like VVF (Vesico Vaginal Fistula), UVF (Uretero Vaginal Fistula), RVF(Recto Vaginal Fistula ) and TVT (Tension Free Vaginal Tape) or TOT (Trans Obturator Tape)
  • Pediatric urology
  • Reconstructive urology like urethroplasty and pyeloplasty
  • Andrology procedures like testicular biopsy (percutaneous and open), microsurgical varicocelectomy, vaso- vasostomy (vasectomy reversal) and treatment of erectile dysfunction
  • Male sexual health services
  • Neuro-urology procedures like uroflowmetry and urodynamic study
  • PCNL (Percutaneous Nephrolithotomy Surgery)
  • URS (Ureterorenoscopy)
  • Flexible URS with Laser Lithotripsy (RIRS –Retrograde Intra Renal Surgery)
  • Laparoscopic stone removal
  • Transurethral crushing of the bladder stone
  • Laser Prostatectomy: HoLEP - LASER – for  nucleation of prostatic lobes
  • Conventional and bipolar TURP (Trans Urethral Resection of the Prostate)
  • Laparoscopic radical prostatectomy
  • Trans Rectal Ultrasonography (TRUS)
 
Anatomy

The urinary tract

The urinary tract consists of the kidneys, ureters, bladder and urethra.

The kidneys are two bean-shaped organs located one on each side of the vertebral column in the abdomen. They are responsible for maintaining fluid and electrolyte balance by removing extra water and waste from the blood and converting it to urine.

Ureters are the narrow tubes that carry urine from the kidneys to the bladder in the lower abdomen. The bladder has elastic walls that expand to store urine. Urine is emptied through the urethra to outside of the body.

Symptoms Of Kidney Diseases

Kidney diseases

Those at risk of developing end stage renal failure include persons with:

  • Symptoms of kidney disease
  • Diabetes
  • Hypertension that is difficult to control
  • Family history of kidney disease, diabetes and hypertension
  • Chronic tobacco consumption, obesity and / or elderly (above 60 years)
  • Chronic intake of pain relievers, e.g. nonsteroidal anti-inflammatory drugs such as ibuprofen, naproxen etc.
  • Congenital defect of urinary tract

Screening in such high-risk individuals helps in early detection and diagnosis of kidney disease.

Early stages of chronic kidney disease are usually asymptomatic, laboratory tests are the only way of detection.

Symptoms of kidney disease

  • Swelling of the face (especially on waking up), abdomen and feet
  • Loss of appetite, nausea, vomiting and intractable hiccups occuring due to accumulation of waste in the blood
  • High blood pressure: can occur at a very young age, or is very high at the time of diagnosis or is intractable
  • Anaemia and weakness: characterised by generalised weakness, early fatigue, poor concentration and pallor
  • Non-specific complaints: Lower back pain, generalised body aches, itching and leg cramps are common. Retardation of growth, short stature and bending of leg bones are common in children with kidney failure.

Urinary complaints like

  • Reduced volume of urine
  • Burning sensation while passing urine (dysuria), frequent urination and passing of blood or pus in urine
  • Obstruction to the normal flow of urine can lead to difficulty in ‘voiding’ and poor stream of urine.

Symptoms of end stage renal disease

  • Nausea
  • Vomiting
  • Loss of appetite
  • Fatigue and weakness
  • Sleep problems
  • Changes in quantity of urine produced
  • Decreased concentration
  • Muscle twitches and cramps
  • Swelling of the face, feet and ankles
  • Persistent itching
  • Chest pain, if fluid builds up around the lining of the heart
  • Shortness of breath, if fluid builds up in the lungs
  • High blood pressure (hypertension) that is difficult to control
Prevent Kidney Disease

Are you at risk?

  • Do you have high blood pressure?
  • Do you suffer from diabetes?
  • Do you have a family history of kidney disease?
  • Are you overweight?
  • Do you smoke?
  • Are you over 50 years?

If you have answered 'yes' to one or more of these questions, you should discuss with your doctor as you may need testing for kidney disease. Early chronic kidney disease (CKD) may not show any signs or symptoms. You can delay or prevent kidney failure by treating kidney disease early.

Did you know?

A person can lose up to 90% of their kidney function before experiencing any symptoms.

How to prevent kidney disease

  • Exercise
  • Keep blood sugar at optimum levels.
  • Monitor blood pressure regularly.
  • A healthy diet and less salt
  • Weight under check
  • Adequate fluid intake. No aerated drinks.
  • Do not smoke or use tobacco in any form.
  • Do not take over-the-counter pills on a regular basis.
  • Get an annual kidney function test if you have one or more of the 'high-risk' factors.
End Stage Renal Disease (ESRD)

End stage renal disease (ESRD)

Kidney failure shows symptoms only when 90 % of renal functions fail. Hence, chronic renal failure is often called a 'silent killer'. The kidneys gradually lose their function and reach an irreversible stage called ESRD. Thereafter, wastes and excess fluid from the body are not removed. The only treatment option is either dialysis or renal transplant.

Causes of ESRD

  • Type 1 or 2 diabetes mellitus
  • Hypertension
  • Glomerulonephritis (an inflammation of the basic filtering units in the kidney)
  • Nephritis (an inflammation of the kidney tubules and surrounding structures)
  • Polycystic kidney disease
  • Kidney infection or pyelonephritis
  • Urinary tract obstruction from enlarged prostate, kidney stones or cancers

Complications

  • Fluid retention, leading to swelling of the face, arms and legs
  • High blood pressure
  • Fluid in the lungs (pulmonary edema)
  • A sudden rise in potassium levels in your blood (hyperkalemia), which impairs heart function and may be life-threatening.
  • Cardiovascular disease
  • Weak bones and an increased risk of bone fractures
  • Anaemia
  • Difficulty concentrating
  • Seizures
  • Increased vulnerability to infections
Kidney Stones

An introduction to kidney stones

Kidney stones are hard, crystalline mineral and acid deposits which form in the kidney or urinary tract. They are sometimes called renal calculi. It is possible for anyone to develop a kidney stone. However, certain diseases and conditions or those who are taking certain medications are more prone to this formation.

Kidney stone disease is the most painful urological disorder. Humans have been suffering from this disorder for centuries. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy.

The incidence of urolithiasis, or stone disease, has increased in the last 25 years. The reasons for this are dietary and climatic changes. Kidney stones are most common in middle-aged people and are 3 times more common in men than in women.

Urbanisation, stress at work and change in food habits are some of the conditions attributed to the increase in the incidence of stone diseases of late.

Risks of developing stones

  • Drinking less fluid
  • Diet with low calcium, high animal protein, high sugars and high sodium
  • Use of calcium supplements
  • Obstruction to urine outflow like in prostate enlargement or stricture disease
  • Hyperparathyroidism (an endocrine disorder that results in more calcium in urine)
  • Gout
  • Obesity
  • Chronic diarrhoea
  • Family history

Causes

  • More calcium, oxalate or uric acid in stones due to metabolic disorder, gout, intestinal bypass surgery or genetic factors
  • Repeated urinary tract infections
  • A family history can be an important factor in kidney stones. They are more common in Asians and Caucasians than in Native Americans, Africans or African Americans.
  • A subset of kidney stones, uric acid kidney stones are more common in people with chronically elevated uric acid levels in their blood.
  • Even pregnancy can sometimes factor in the formation of kidney stones. The reason for this is that the passage of urine slows down in the woman due to increased secretion of the progesterone hormone. To add to this, the enlarged uterus results in a lower bladder capacity during pregnancy. This then leads to lower fluid intake which further aggravates the situation.
  • Dehydration from reduced fluid intake or strenuous exercise without necessary fluid replacement increases the risk of kidney stones.

Symptoms

The symptoms depend upon where the stone is located

  • If the stone is in the kidney: dull aching continuous pain in the loins, repeated urinary tract infections or sometimes intermittent blood in the urine, especially in a young adult
  • If the stone is in the ureter: Stones usually at least 3 mm can cause obstruction of the ureter. Ureteral obstruction causes hydronephrosis (distension and dilation of the renal pelvis and calyces) as well as spasm of the ureter. This leads to pain, most commonly felt in the flank (the area between the ribs and hip), lower abdomen and groin (a condition called renal colic). Renal colic can be associated with nausea, vomiting, sweating, urinary urgency, blood in the urine and painful urination. Renal colic typically comes in waves lasting from minutes to hours, beginning in the flank or lower back and often radiating to the groin or genitals. It is caused by contractions of the ureter as it attempts to expel the stone.
  • Sometimes patient presents with lithuria : eliminating gravel or stones while passing urine
  • Sometimes they are asymptomatic, especially when it is present in the kidney. A large kidney stone shaped like a like stag horn which occupies more than 80% of the kidney may not produce any symptoms and come to light when undergoing evaluation for some other diseases.

How is it diagnosed?

Diagnosis is made on the basis of:

  • Clinical findings
  • X- ray of abdomen
  • Ultrasonography
  • Urine examination
  • Sometimes advanced tests like spiral CT or contrast CT may be required.

Is recurrence common even after complete removal of stones?

  • Stone recurrence is very common. If not treated, there is a 20-30% chance that it recurs within 2 years, 50% chance within 5 years and 65% chance in 10 years.
  • If treated appropriately with diet modifications to reduce the stone formers in the body, chances of recurrence can be reduced.

What are the complications of stone disease?

  • Repeated infection / pyelonephritis etc.
  • Obstruction may lead to temporary kidney failure with rise in serum creatinine.
  • If obstruction is repeated and not treated, especially in those with other associated systemic diseases, it might lead to permanent renal failure needing dialysis and renal transplant.
  • Renal failure i.e. chronic kidney diseases

Treatment

Medical management: for those who pass small stones in urine or are asymptomatic. These patients should undergo complete investigations, blood and urinary metabolic evaluation to find out the cause and be treated.

Surgery: These are patients who have stones causing obstruction, blood in the urine, repeated infection and malfunctioning of the kidneys. These patients may require early surgical intervention to prevent complications.

Surgery options

  • Extracorporeal shock wave lithotripsy (ESWL): for the moderate sized soft stone located in the kidney or ureter where the stone is fragmented using a lithotriptor via the shockwave delivered from outside the body. The main advantage is that the procedure can be done in an outpatient setting.
  • Endoscopic removal for the stones in the lower ureter
  • Flexible ureteroscopy and laser disintegration for the stones in the complex inaccessible part of the urinary system
  • Percutaneous nephrolithotomy (PCNL) for the large stones of the kidney
  • Laparoscopic method is often used to treat complex pelvic stones.
  • Open surgery in selected cases

Surgical treatment of stones includes:

  • Shock wave lithotripsy (ESWL)
  • Ureteroscopy (URS)
  • Retrograde intrarenal surgery (RIRS)
  • Percutaneous nephrolithotomy (PCNL)
  • Laparoscopic open surgery

Semi rigid ureteroscopy

This is an endoscopic method where a miniature (6 fr) scope is passed through the urethra and the stones are fragmented and removed under direct vision. This method is commonly used for the removal of stones when they are present in the mid and lower ureter and sometimes for the large upper ureteric stones. In this method, the stone is directly visualised and broken with pneumatic or ultrasonic lithotripsy or using laser. The main advantage is complete stone clearance in a single stay.

Retrograde intra renal surgery(RIRS)

This is an advanced endoscopic technique of fragmenting the stone in situ using a flexible ureteroscope and laser. Here, the stone is approached anywhere in the calyces of the kidney. Most of the complex small stones in the kidney can be tackled by this method. It is one of the most favoured approaches for stone treatment currently.

Percutaneous nephrolithotomy (PCNL):

Here, the kidney is directly punctured through the skin and a tract is made to approach the stone. Then the endoscope (nephroscope) is used to visualise the stone and is fragmented by the available energy sources and laser. This method is useful in large stone bulk within the kidney. Patient needs to stay in the hospital for 4-5 days.

Laparoscopic / open-stone removal

Open surgery: because these procedures are the most invasive and painful, patients often spend up to 5-7 days in the hospital. Complete recovery may take up to six weeks. Present day indications for open surgery for stone removal are only 2%.

This procedure is replaced by minimally invasive laparoscopic method. Here, the stone is removed via a keyhole surgery technique. Most of the stones can be removed effectively by laparoscopic methods. Laparoscopy has the advantage of minimal scarring, less pain, immediate recovery and early return to work.

Benign Prostatic Hyperplasia (BPH)

Benign prostatic hyperplasia (BPH)

The prostate is a walnut-sized gland that forms part of the male reproductive system. It is located in front of the rectum and just below the urinary bladder. It surrounds the urethra, the tube through which urine passes out of the body. The prostate is made of two or three lobes. Its function is to squeeze fluid into the urethra as sperms move through, during sexual climax. This fluid, which helps make up semen, energizes the sperm and makes the vaginal canal less acidic.

Normal prostate weighs 10-15 gm. Prostate enlargement happens to almost all men as they get older. As the prostate enlarges, it presses against the urethra like a clamp. The bladder wall becomes thicker and irritable. The bladder begins to contract even when it contains small amounts of urine, causing more frequent urination. Eventually, the bladder weakens and loses the ability to empty itself, so some of the urine remains in the bladder. The narrowing of the urethra and partial emptying of the bladder cause many of the problems associated with BPH

An enlarged prostate is often called benign prostatic hyperplasia.

What is BPH?

BPH is an enlarged prostate, which as it enlarges, can squeeze down on the urethra. The bladder wall becomes thicker. Eventually, the bladder may weaken and lose the ability to empty completely, leaving some urine in the bladder. BPH is a naturally aging process.

Causes

The cause of BPH is not well understood. No definite information on risk factors exists. A small amount of prostate enlargement is present in many men over age 40 and more than 90% of men over age 80.

Symptoms

The size of the prostate does not always correspond to the obstruction or the symptoms it produces. Some men with greatly enlarged glands have little obstruction and few symptoms while others, with lesser enlargements, have more blockage and severe symptoms.

Symptoms include:

  • A weak or slow urine stream
  • A feeling of incomplete bladder emptying
  • Difficulty starting urination
  • Frequent urination
  • Urgency to urinate
  • Getting up frequently at night to urinate
  • A urinary stream that starts and stops
  • Straining to urinate
  • Continued dribbling of urine
  • Pain with urination or bloody urine (these may indicate infection)
  • Inability to urinate (urinary retention)

Clinical evaluation and tests / investigations

Several tests help to identify the problem and decide whether surgery is needed.

  • Complete medical history - including other medical conditions.
  • Digital rectal exam to feel the prostate gland.
  • Uroflowmetry - urine flow rate
  • Post-void residual urine on sonography to see how much urine is left in the bladder after urination
  • Urodynamic study - pressure flow studies to measure the pressure changes in the bladder during urination.
  • Urinalysis & urine culture to check for blood or infection
  • Prostate-specific antigen (PSA) blood test to screen for prostate cancer
  • Trans rectal ultrasound and prostate biopsy - if there is a suspicion of prostate cancer, this test is recommended.
  • Cystoscopy - to see the inside of the urethra and the bladder. This test determines the size of the gland and identifies the location and degree of the obstruction.

Complications

Men who have had long-standing BPH with a gradual increase in symptoms may develop:

  • Urinary tract infections
  • Blood in the urine
  • Urinary stones
  • Damage to the kidneys
  • Urinary retention

Treatment

The choice of a treatment is based on the severity of the symptoms and the presence of other medical conditions.

Men with an enlarged prostate, having only minor symptoms need watchful waiting with regular check up - a yearly examination to monitor the progression of symptoms and to determine if any treatment is necessary.

For minor symptoms, lifestyle changes like:

  • Avoid alcohol and caffeine, especially after dinner.
  • Fluid intake: Not to drink a lot of fluid all at once. Spread out fluids throughout the day. Avoid drinking fluids within 2 hours of bedtime.
  • Avoid medication that contains decongestants or antihistamines. These medications can increase BPH symptoms.

Medications

  • Alpha 1-blockers (tamsulosin and alfuzosin) are medications which relax the muscles of the bladder neck and prostate. This allows easier urination.
  • Finasteride and dutasteride lower levels of hormones produced by the prostate, reduce the size of the prostate gland, increase urine flow rate, and decrease symptoms of BPH. Potential side effects related to the use of finasteride and dutasteride include decreased sex drive and impotence.

Antibiotics may be prescribed to treat associated prostatitis.

Surgery

Surgical intervention is recommended if there is:

  • Incontinence
  • Recurrent blood in the urine
  • Inability to fully empty the bladder (urinary retention)
  • Recurrent urinary tract infections
  • Kidney failure
  • Bladder stones
  • Non responsive to medical management
  • Severe persistent symptoms obstructing daily activities
  • Retention of urine not relieved by medicines

The choice of a specific surgical procedure is based on the severity of symptoms, risk status of the patient and the size and shape of prostate gland. Following are the surgical options procedure s for the treatment of prostate enlargement

Transurethral resection of the prostate (TURP):

It is the most common surgical treatment for BPH and is performed by inserting a resectoscope, through the urethra which has an electrical loop that cuts prostatic tissue and seals blood vessels. This surgery requires anesthesia and a hospital stay of 3-4 days.

Bipolar PK TURP – TURIS:

Transurethral resection on saline; the procedure is same as above, however it is safer and has minimal post operative symptoms like burning urine and urgency etc. This procedure can be done for those with chronic kidney diseases and some high risk individuals.

Modified PK TURP:

This is a modification of the above procedure where in this procedure thought to prevent the retrograde ejaculation in 70% of the patients treated. Here either the bladder neck is incisedor some part of the apex flap is retained so that ejaculatory function is preserved. case selection is important and will be decided by the treatment urologist.

Miniature TURP: Those patients who have small caliber urethra since birth or due to some diseases / illnesses, can be offered miniature TURP , where in small telescopes are used with out damaging the urethral passage while performing prostate surgery.

Open prostatectomy:

It is usually performed using general or spinal anesthesia. An incision is made through the abdomen or perineum (the area behind the scrotum). Only the inner part of the prostate gland is removed. The outer portion is left behind. This is a lengthy procedure, and it usually requires a hospital stay of 5 to 10 days.

Laparoscopic prostatectomy:

Commonly done for cancerous condition of the patients , this procedure can also be done for grossly enlarged prostate where in 2 small telescopes are put into the bladder and the prostate enucleated and removed via small abdominal wall incision.

Laser surgery for prostate:

This surgical procedure employs lasers to vaporise / cut / resect and enucleate the prostate tissue, which is causing the obstruction. The laser fiber is passed through the urethra into the prostate using a cystoscope. The laser energy destroys prostate tissue. Laser surgery requires anaesthesia either local or general (depending on the patient condition) and a minimal hospital stay of 1-2 days. Laser surgery also ensures a quicker recovery time.However, there are various laser technologies which are tailored to suit each patient and size of the prostate. The treating doctors will be able to determine which LASER is best for aparticular clinical scenario.

KTP laser; PVP

Photo selective vaporisation of the prostate; here the potassium titanyl phosphate laser is used to destroy / vaporise the prostate tissue.

Advantages

  • It is blood less
  • Can be used under local anesthesia
  • Old age
  • Those patients who are on antiplatelet (blood thinners): Procedure can be done even without stopping theses medications
  • Patients with severe medical conditions, including uncontrolled diabetes and serious lung, kidney or heart disease etc.

Disadvantages

  • This type of Laser surgery may not be effective on larger prostates.

HoLEP; holmium laser enucleation of the prostate:

Here the high power holmuim laser energy is used to resect / enucleate the prostate in very effective manner. Unlike PVP, size of the prostate gland does not preclude the use of Holmium laser for surgical treatment of BPH. Currently HoLEP is the only procedure to treat larger prostates. The entire lobes are enucleated, moved into the bladder and morcellated or fragmented.

Advantages

  • Minimal hospital stay
  • Low recurrence rates
  • Only treatment of choice for prostate of larger seizes (>80-100 gm ). Even prostate upto 350 gm has been done by Columbia Asia Hospitals
  • Very effective treatment modality for recurrent prostate problem and enlargement(revision prostatectomy)
  • Min blood loss
  • High-risk individuals
  • Those are on blood thinners with prostates >50 gm with symptoms of prostate enlargement /or obstruction
  • This procedure ensures the removal of 80% of the gland
  • Lowest recurrence …as per the world wide literature

Disadvantages

  • Patient may experience a little incontinence initially, however resolves over a period of time

Sexual function after prostate surgery

Most men find little or no difference in the sensation of orgasm, or sexual climax, before and after surgery. Although most men are able to continue having erections after surgery, a prostate procedure frequently causes a condition called retrograde ejaculation or dry climax. This is because prostate surgery widens the neck of the bladder. Following surgery, the semen takes the path of least resistance and enters the wider opening to the bladder rather than being expelled through the penis. Some young men can undergo apical preserving bipolar TURP – which may prevent this complication in selected patients.

Recurrence

Surgery usually offers relief from BPH for at least 15 years. Only 10% of the men who have surgery for BPH eventually need a second operation for enlargement. Holep reduces the recurrence to < 1% in 10 years. Usually these are men who had the first surgery at an early age.

BPH and prostate cancer: No apparent relation

Although some of the signs of BPH and prostate cancer are the same, having BPH does not increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have undetected prostate cancer at the same time or may develop prostate cancer in the future. For this reason, it is recommended that all men over 40 have a rectal examination once a year to screen for prostate cancer.

After BPH surgery, the tissue removed is routinely checked for hidden cancer cells.

Prostate Cancer

The prostate is a walnut-shaped gland in men that produces seminal fluid that nourishes and transports sperm.

Prostate cancer is one of the most common cancers in men. It usually grows slowly and may spread to other organs if left undetected and untreated.

Prostate cancer may cause no signs or symptoms in its early stages.

Symptoms

Prostate cancer that is more advanced may cause signs and symptoms such as:

  • Burning or pain during urination
  • Trouble starting and stopping urination
  • Increased frequency of urination, especially at night
  • Loss of bladder control, so there may be incontinence
  • Decreased force in the stream of urine
  • Blood in semen or urine
  • Discomfort in the pelvic area
  • Bone pain
  • Erectile dysfunction

Risk factors

  • Age: risk increases with age.
  • Family history of prostate or breast cancer increases risk.
  • Obesity increases the risk of getting a more aggressive cancer that is difficult to treat.

Complications

  • Cancer spreads (metastasises) to nearby organs, such as your bladder or travels through your bloodstream or lymphatic system to your bones or other organs.
  • Incontinence: Both prostate cancer and its treatment can cause urinary incontinence.
  • Erectile dysfunction: It can result from prostate cancer or its treatment, including surgery, radiation or hormone treatments.

Prevention

  • A healthy diet: with plenty of fruits, vegetables and whole grains. Avoid high-fat foods.
  • Regular exercise
  • Maintain a healthy weight

Screening

  • Screening to commence at:
    1. Age 50 for men who are at average risk and expected to live at least 10 more years
    2. Age 45 for men at high risk; who have first degree relatives with prostate cancer at younger ages below 65 years
    3. Age 40 for men at very high risk; who have many first degree relatives with prostate cancer at an early age
  • Digital rectal examination
  • Prostate specific antigen test

If no prostate cancer is found as a result of screening, the time between future screenings depends on the results of the PSA blood test:

  • Men who have a PSA of less than 2.5 ng / mL may only need to be retested every 2 years.
  • Screening should be done yearly for men whose PSA level is 2.5 ng / mL or higher.
  • Because prostate cancer often grows slowly, men without symptoms of prostate cancer who do not have a 10-year life expectancy need not undergo testing since they are not likely to benefit.

If the screening tests suggest prostate cancer, the following is done:

  • Transrectal ultra sound (TRUS): A small probe is passed into the rectum and images visualised
  • A prostate biopsy is done using a small needle which is passed through the rectal wall using transrectal ultrasound to visualise the prostate.