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About Urology

What is Urology?

Urology is a surgical specialty that deals with diseases of the Genito-urinary tract in men and women. The broad areas covered under general Urology are as follows.

  • Hematuria (Blood in the urine)
  • Prostate Disease (Any urinary problem in men aged 50 and above)
  • Urinary tract infections
  • Benign and Malignant tumors of the genitourinary tract
  • Conditions affecting the penis, testes, and scrotum
  • Male Infertility
  • Erectile dysfunction
  • Trauma to the genitourinary organs
  • Inflammatory and infectious diseases of the urinary and genital tract

What is the difference between a Urologist and a Nephrologist?

Because urologists and nephrologists both treat kidney problems, knowing which type of doctor to see can be confusing. Urologists are surgical specialists who focus on anatomical or structural disorders of the kidneys and urinary tract. They treat problems such as kidney stones, kidney blockages, and kidney cancer. Urologists are qualified to perform surgery and outpatient medical procedures to correct such conditions.

Nephrologists are medical specialists who focus on disorders that affect the way the kidneys work such as diabetes and chronic kidney disease. Nephrologists prescribe nonsurgical medical treatments for these disorders.
The roles of nephrologists and urologists often overlap and they work together on conditions having both medical and surgical requirements.

  • Uroflowmetry
  • Ultrasonography
  • Endo – Urology

What is Endourology?

Endourology is a minimally invasive technique available to treat kidney stones. Stones may be extracted or fragmented using tiny instruments through natural body channels such as the urethra, bladder and ureter. Thin, flexible instruments including lasers, graspers, miniature stone retrieval baskets, special scalpels, and cautery, can be advanced through working channels in the scopes in order to perform surgery without creating any incisions at all. The majority of endoscopic procedures can be done on an outpatient basis.
Endourological procedures include:

  • Urethroscopy: used to treat strictures or blockages of the urethra.
  • Cystoscopy: used to treat bladder stones and tumors. Obstructing prostate tissue can be removed with this approach as well (a procedure called “TURP”). Flexible plastic tubes called stents can be passed up the ureter using cystoscopy and x-rays to relieve blockage of the ureter.
  • Ureteroscopy: used to treat stones and tumors of the ureter.
  • Nephroscopy: used to treat stones and tumors of the kidney lining.

What is Urology?

Urology is a surgical specialty that deals with the treatment of conditions involving the male and female urinary tract and the male reproductive organs.

People specializing in the field of urology are called urologists, healthcare professionals who are trained to diagnose, detect and treat this group of disorders and diseases.

The disorders that may be treated by urologists include those involving the kidneys, the ureters (tubes connecting the kidneys to the bladder), the adrenal glands, the bladder and the urethra (the tube that passes urine out of the body from the bladder). In males, a urologist may also treat conditions of the testes, epididymis, vas deferens, seminal vesicles, prostate, and penis. The field of urology involves the medical management of conditions such as urinary tract infection and prostate enlargement through the surgical management of conditions such as bladder cancer, prostate cancer, kidney stones and stress incontinence.

In the case of certain conditions such as cancer of the urinary tract, urologists may need to work in conjunction with oncologists or radiotherapists. They may also need to collaborate with nephrologists who deal with kidney conditions, gynecologists who deal with the female reproductive system and endocrinologists who are concerned with conditions of the endocrine system and hormone disorders. Urologists may also collaborate with practitioners of pediatric surgery and colorectal surgery.

Urologists undergo post-graduate training for five years, completing 12 months in general surgery and 36 months in clinical urology. The remaining time is spent training in general surgery, clinical urology or a discipline that is relevant to urology. There are several specialist areas that can be practiced after completion of a urology degree.

Q. What types of Endoscopic procedures are there?

Extracorporeal Shock Wave Lithotripsy :

This minimally invasive technique for the disintegration of stones involves the administration of shock waves that are generated by a machine called a lithotriptor. After the machine is calibrated, and the stone has been targeted, shock waves are focused and passed through the body in such a manner that their maximum energy is dispersed at the locale of the stone, with the intent of stone disintegration. The pulverized fragments then pass in the patients urine. The procedure works best for smaller stones. Other determinants for success with this treatment technique include stone composition and the specific anatomic location of the stone within the urinary tract.

Ureteroscopy :

The ureters are narrow conduits (tubes) that carry urine from the kidney down to the bladder. They are normally quite small in caliber, but may become dilated (wider) when they are obstructed. Ureteroscopes are precision instruments used for surgical procedures within these structures. At times an ureteroscope may also be used to traverse the length of the ureter in order to perform a procedure in the kidney.

Ureteroscopic treatment of stones :

In certain cases, ureteroscopy is the most effective treatment for urinary stones. The following are specific situations where ureteroscopy is the treatment of choice:

  • Where stones have not been completely broken up and cannot passed through the urine after treatment with extracorporeal shock wave lithotripsy;
  • When stones are lodged in the portion of the ureter near the bladder, a region where a shock wave lithotriptor may have difficulty focusing shock waves for breakage of the stone;
  • When there are stones in particular parts of the kidney (the lower portion) that even if broken up by extracorporeal shock wave lithotripsy, cannot, due to contour and angulation, pass out of the kidney;
  • Where stones are associated with other unusual ureteral/kidney anatomy.

Various devices can be placed through the ureteroscope to facilitate stone breakage and removal. These include lasers, miniature jackhammer like stone impactors, and other similar tools that cause stones to fragment when these devices are activated. Miniature baskets can also be placed for removal of stone fragments. The narrow ureter oftentimes swells in reaction to stone treatment, and as such, a stent, a tube resembling a thin drinking straw with curls on each end, is placed in the ureter for a few days until this swelling subsides. This stent is easily removed in the outpatient clinic shortly after the procedure.

Ureteroscopic treatment of ureteral/renal strictures and other renal disorders

Due to a variety of causes, including stones that remained impacted in the ureter for a long time, the ureter may stricture; that is to say, scar and narrow to a point where urine cannot readily pass. In these situations, the obstruction of urinary flow often results in pain. However; if obstruction is slow in onset, the patient may not notice pain specifically related to the kidney. The obstruction of urinary flow, if not relieved, will eventually result in kidney damage. These obstructions must be treated. Strictures of short length and duration can be cut open with a laser or other device placed through a ureteroscope. A stent is then placed while the ureter heals. Strictures that are longstanding and of longer length and complexity may require repeat procedures, or a more complex procedure, such as laparoscopy or open surgery, for correction.

Percutaneous Renal Surgery

Percutaneous renal surgery involves the placement of catheters through the skin in the patients back into the drainage system of the kidney. Subsequently this passageway can be dilated to facilitate the placement of working tubes and instruments to break up/remove stones and to perform other necessary procedures (including relief of kidney obstruction). Though more invasive than extracorporeal shockwave lithotripsy and ureteroscopy, this procedure offers substantial benefits in terms of patient recovery when compared to open surgical procedures that, in the past, often had to be performed to treat large kidney stones or other significant kidney diseases.

Percutaneous Removal of Stones

Large kidney stones often cannot be effectively treated by extracorporeal shock wave lithotripsy or ureteroscopy. Though these procedures can be attempted, their limitations may become evident. Extracorporeal shock wave lithotripsy can be performed, but it can be difficult to break a large stone in its entirety by this means. Furthermore the fragments that are broken must all pass, which may cause significant discomfort for the patient for a prolonged period of time. It then becomes necessary for more procedures, which require anesthesia, to be performed to remove the residual stone. Ureteroscopy can also be performed, but because the ureteroscope and the ureter are of small caliber, it may be difficult to break a large stone by this means, and then remove all of the fragments. Once again, a greater number of procedures, which require anesthesia, may need to be performed.

Due to these limitations percutaneous removal of large kidney stones is often necessary. Through a tube passed directly into the kidney, larger instruments and devices can be placed directly into the kidney for stone breakage and removal. Even large stones can be removed in one procedure. For very large stones, a second look procedure, to clear residual stone fragments, is often necessary. Due to the nature of this procedure, which involves placement of surgical instruments through the kidney itself, a small chance of transfusion exists. Most patients stay in the hospital overnight after this procedure.

Percutaneous treatment of renal obstruction

Kidney obstruction may occur due to problems such as scarring or stricturing of the ureter. Many of these obstructive processes can be managed with ureteroscopy or percutaneous surgery. The nature and complexity of the obstruction often dictate which of these methods will be necessary. For less complex obstructions, the less invasive ureteroscopic means can possibly be used, but for more complex obstructions, which are usually related to specific aspects of the anatomy of the kidney, the percutaneous method may be necessary.

Laparoscopic Uro-Oncology

Almost all urological cancers can be treated with laparoscopy.

Laparoscopic radical prostatectomy (LRP)

This is a type of keyhole surgery used to remove the prostate gland and the seminal vesicles as a treatment option for prostate cancer.

Traditionally radical prostatectomy was performed through a single incision that extended from the pubic bone to just below the umbilicus (belly button). This is not the case for LRP which uses instead, 5 small incisions through which ports or small tubes are placed. Specialized instruments and telescopic cameras are then inserted through the ports to perform the surgery in a precise manner facilitated by magnified vision.
The suitability of a man for this type of surgery will depend on several factors. Most importantly is the type of prostate cancer that a man has. This will be determined predominantly by three main characteristics:

  • Initial PSA
  • Gleason score (appearance of the prostate cancer demonstrated in the biopsies)
  • DRE findings (how the prostate feels when examined by the urologist)

The advantages of LRP are that of improved visualization, reduced post operative pain, a shorter hospital stay and a more rapid return to normal activity

Laparoscopic radical nephrectomy

Laparoscopic radical nephrectomy uses a minimally invasive approach (laparoscopy) to perform exactly the same procedure that is done in open radical nephrectomy. In any radical nephrectomy (open or laparoscopic) 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. The operation also often includes removal of the lymph nodes which are around the kidney.

The laparoscopic approach to partial nephrectomy means that no large incisions are required to perform the procedure. Instead of a large incision, three or four 1/2 cm to 1 cm incisions (less than 1/2 inch) are made. The spaces in the body are gently filled with gas to make working space and a small camera is placed into the body through one of the incisions. The other small incisions are used to place working instruments which can be used to perform the procedure.

The entire kidney with the cancer within and with the surrounding fat and the layer known as Gerotas fascia are removed. Once the entire specimen has been separated from the surrounding tissues, it is placed in a bag while still inside the body. The bag is then removed by making an incision.

Reconstructive Urology

Reconstructive urology is different from mainstream urology because it is mainly open surgery and depends on a greater than usual familiarity with general surgical and plastic surgical techniques. There is a considerable overlap with female urology in the area of complex incontinence and fistula. There is some overlap with paediatric and adolescent urology in the reconstruction of congenital malformations, and in neuropathic bladder dysfunction, and there is some overlap with urological oncology in the area of bladder replacement. There is some overlap too with andrology in the are of penile reconstruction in congenital and traumatic conditions.

Problems treated with reconstructive Urology include

  • Urethral disruption injuries from pelvic fracture
  • Recto-urinary fistulas after prostatectomy or pelvic surgery
  • Refractory male urethral strictures
  • Radiation-induced urinary fistulas
  • Major bladder reconstruction urinary diversion, continent catherizable stomas (Mitrofanoff, Monti), neobladder, augmentation cystoplasty, MACE (antegrade continent enema)
  • Major ureter reconstruction – Boari flap, Psoas hitch, ileal ureter, trans-ureteroureterostomy, complex pyleoplasty
  • Vesicovaginal or ureterovaginal fistulas after pelvic surgery
  • Male urinary incontinence artificial urinary sphincter, male sling, bulking agents
  • Peyronies disease plaque incision and grafting, penile placation.

Female – Urology

Urinary incontinence and pelvic floor weakness or prolapse (“dropped bladder”) are common in women who are middle aged and older. Our Centre provides a complete range of diagnostic procedures and treatments ranging from behaviour modification with strengthening of the pelvic floor muscles to minimally invasive Tape procedures to complex reconstructive surgery

Laparoscopic Urology

Laparoscopic (keyhole) surgery is the art of performing surgical operations through several small incisions rather than using a traditional large single incision. Telescopic cameras are then passed through ports or small tubes in the abdominal wall to facilitate improved visualization and to allow precise surgery.

Laparoscopy (keyhole surgery) can be used to perform several different urological operations. These include:

  • Radical prostatectomy: Surgery to completely remove the prostate and seminal vesicles because of prostate cancer
  • Nephrectomy: removal of the kidney. This can be required, most commonly, as a result of loss of function or as a result of an abnormal growth
  • Pyeloplasty: This allows improved drainage of urine from a kidney that has a blockage

What are the advantages of Laparoscopy?

  • Surgeons have known for at least a decade that patients use fewer painkillers after laparoscopic surgery, go home earlier and return to normal activities and work sooner than after traditional surgery
  • A better cosmetic result
  • Gentler, more accurate and magnified surgery with less bleeding

Retrograde Intra Renal Surgery

Retrograde Intrarenal Surgery (RIRS) allows the surgeon to do surgery inside the kidney without making an incision. The instrument for RIRS enters through the body’s natural opening, through the bladder and the ureter, into the kidney.

RIRS is used for patients with stones in the kidney, narrowing of the outlet of the kidney or within the kidney (strictures) and tumors in the kidney. The RIRS is an outpatient procedure using local, intravenous or general anesthesia.

The Minimally Invasive Urology Institute specializes in using RIRS for difficult-to-treat cases, such as:

  • Failed previous treatment attempts
  • Stones too large for ESWL (lithotripsy)
  • Strictures
  • Tumors
  • Stones in children
  • Patients with bleeding disorders
  • Patients with gross obesity

This procedure is done with flexible ureteroscopy and Laser.

Neuro – Urology

Neuro-urology focuses on disorders or conditions of the bladder, urinary tract, kidneys and genitalia related to neurological disorders and spinal injuries. For example, patients with neurological conditions such as Stroke, Parkinsons disease, multiple sclerosis or spinal cord injury may experience problems such as overactive bladder or sexual dysfunction. Neuro-urology involves diagnosing the type of bladder problem and treating it through medication, behavioural changes or surgery.

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