Urology Treatments

Transurethral Resection of Prostate or T.U.R.-Prostate or T.U.R.P. is a treatment of choice if the enlarged prostate gland compresses on the urethra resulting in obstruction of urinary outflow. In the TURP, the glandular tissue is removed in small chips or pieces as opposed to Radical Prostatectomy where the prostate gland is removed in it’s entirety. T.U.R.P. is an endoscopic procedure where the prostate gland can be visualized while it is being resected.

Prostatic surgery or Prostatectomy comprises other form of surgery such as Suprapubic prostatectomy, Transurethral resection of the prostate(TURP), Open prostatectomy, Laser prostatectomy, Transurethral needle ablation,(TUNA). On the basis of the size of the prostate gland, different kind of prostatic procedures are decided. TURP is performed on the glands bigger than 30 grams and less than 80 grams. But if the prostate gland is bigger than 90 grams, open prostatectomy is performed. Prostatic surgery is not performed on the patients having bood clotting disorder or bladder disease (neurogenic bladder).

• Irregular or absent periods
• Hormone imbalance
• Smoking or alcohol use
• Endometriosis
• Fibroids
• History of infertility

Minimally Invasive Laser Prostate (TURP) Surgery in India

Laser Prostatectomy

Laser prostatectomy or Laser for prostatic surgery is recently developed minimally invasive treatment modalities for patients having BPH i.e benign prostatic hyperplasia or benign prostatic hypertrophy. The term Benign prostatic hyperplasia or benign prostatic hypertrophy means increase in size of the prostate gland in the men above 50 years of age. Laser Prostatectomy is used mainly to remove the prostate gland when there is no cancer in it but its size enlarges due to which it creates problem in the urinary tract. Laser prostatectomy is a short and easy procedure, usually after which the patient can return to their home on the day of operation itself.

Procedure for laser prostatic Surgery

Patients who has a history of BPH are recommended by their doctors to undergo laser prostatic surgery as because they cannot be treated by the medical therapy. Before the surgery the patients has to undergo several preoperative measurements like American Urologic Association symptom score, Uroflowmetry, Prostate-specific antigen and Transrectalultrasonography (TRUS). Laser prostatectomy uses beams of light to destroy prostate tissue. It is mainly done under the use of regional anesthesia. This laser beam helps in destroying any prostate tissue which blocks the opening of the urethra and bladder outlet. After the laser prostatic surgery, the rate of urine flow improves and reduces the symptoms of BPH. A Foley catheter may be placed in the patient body after the surgery to help in emptying the bladder. For few days after the surgery catheter usually remains in place.

Types of Most Advanced Minimally Invasive Laser Prostate (TURP) Surgery in India

Greenlight Laser Treatment For Benign Prostatic Hyperplasia

The GreenLight Laser treatment therapy is the most effective, novel and advanced technique for the treatment of an enlarged prostate, which is clinically referred to as Benign Prostratic Hyperplasia (BPH). The treatment involves a laser beam therapy which evaporates the enlarged prostatic tissue that presses on the outlet of the urinary bladder causing urinary outflow obstruction symptoms. The procedure involves the use of a high powered system (80-120 watts), which generates laser beams, which vaporizes the extra prostatic tissue. This is unlike other procedures like Transurethral Resection of the Prostate (TURP), which use electrical current to burn the tissue, and also puts the surrounding structures at risk of being burnt and destroyed.

Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic. A catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.

Conventional vs Laser Prostatectomy/ TURP:

• For the conventional TURP, the resectoscope, a combined visual and surgical instrument is used, whereas the Laser procedure involves use of advanced laser energy to cut excess gland, thus there is no loss of blood & shorter hospitalization is required
• Blood thinning agents have to be stopped a week to 10 days before the procedure for conventional TURP, which puts the heart at risk, whereas the laser TURP is done with the blood thinning agents on board, which is highly beneficial for cardiac patients.
• Conventional TURP allows tissue removal at only 1gram/min, whereas laser can vaporize tissue as fast as 3-4 grams/ min.
• For prostates larger than 100gm, open surgery is required in case of conventional TURP, whereas lasers can effectively perform surgery in such large prostate cases

A radical prostatectomy is a common operation for treating prostate cancer. It used to be called total prostatectomy. This means using surgery to remove all of the prostate gland through a cut in your abdomen or the area between the testicles and the back passage (perineum). The aim of this type of surgery is to cure the cancer. Your surgeon may suggest radical prostatectomy if

• Your cancer has not spread outside your prostate
• You are younger, rather than older, and have a high grade tumour.

How radical prostatectomy is done ?

A radical prostatectomy is carried out by specialist surgeons. They take out the whole prostate gland with the aim of getting rid of all the cancer. The surgeon makes a cut in the abdomen (retropubic) or between the testicles and the back passage (perineal). This operation is called open prostatectomy. As well as the prostate gland, the surgeon also removes the surrounding tissues and the tubes that carry semen (seminal vesicles). They then close the wound.

Laparoscopic prostatectomy (keyhole surgery)

Often, a radical prostatectomy is done using keyhole (laparoscopic) surgery. The surgeon uses a tube with a light and eyepiece to look inside the body. They fill the abdomen with carbon dioxide gas so they can see the prostate clearly. A tiny video camera gives a magnified view of the prostate gland on a video screen. The surgeon cuts away the prostate gland from the surrounding tissues and puts it in a small bag before removing it through one of the cuts in the abdomen. The main difference with this surgery is that you won’t have a big wound in your abdomen afterwards. Instead you have several small cuts.

Laparoscopic surgery is as good at treating prostate cancer as open surgery. Men also lose less blood, have less pain, and spend less time in hospital. Most men also recover and go back to normal activities more quickly than with open radical prostatectomy surgery. Two of the most common side effects of prostatectomy are problems with control over when to pass urine (urinary incontinence) and inability to have an erection (impotence). There doesn’t seem to be any difference in the number of men who have these side effects after open prostatectomy or after laparoscopic prostatectomy.

What are the Benefits and Risks of Radical prostatectomy?

If you’re young and in good health, the short-term risks of this surgery are low. The hospital stay is usually 2 to 3 days, with the catheter left in place for 2 to 3 weeks. You’re usually able to go back to work in about 1 month. You shouldn’t have severe pain with this surgery. Most men regain bladder control a few weeks to several months after the surgery.

The main advantage of surgery is that it offers the most certain treatment. That is, if all of the cancer is removed during surgery, you are probably cured. Also, the surgery provides your doctor with accurate information about how advanced your cancer is, since the nearby lymph nodes are taken out along with the tumor.

Holmium Laser Enucleation of the prostate (HoLEP) is a modern alternative to the standard Transurethral Resection of the Prostate (TURP) procedure for bladder outflow obstruction due to BPH. It requires a short period of hospitalisation and an anaesthetic. A catheter (a tube which drains the bladder) is also needed for 1-2 days until the urine clears. Patients are advised to take life quietly and to avoid straining or heavy lifting for four weeks after the surgery.

Surgery does have risks. The main risks of radical prostatectomy are incontinence (loss of bladder control) and impotence (loss of the ability to get or keep an erection long enough to have sex). Most bladder and impotence problems improve with time.

Robotic surgery involves use of the da Vinci robotic surgical unit in performing complex surgical procedures such as prostatectomy (removal of the prostate gland for cancer). Originally developed for space and military uses, this advanced technology allows the operating surgeon to sit behind a console and control the robot that is next to the patient to perform surgery.

This technology allows the surgeon to operate with very small and precise instruments under a 3 dimensional (3-D) vision, which is magnified up to 10 times. This is achieved by inserting the camera and the instruments into the patient’s body through small cuts (incisions) ranging from 5 – 12 mm in size.

Da Vinci Master Slave Robotic System

The surgical application of robotic systems is one of the most exciting and significant technological developments of this century; its future implications are incalculable.Huge strides have been made in the field of closed operations in the past 10 years and the use of robotic systems has emerged as the principle solution to technical limitations

The use of robotic surgical systems has numerous advantages. Whereas modern laparoscopic systems give only a two-dimensional vision, robotic systems give the surgeon a three-dimensional field of vision and depth, provide arms that, unlike the human hand, never tire and permit an unprecedented continuityin operations. Since robotic systemsexceed even the human hand’s freedom and facility of movement, far greater delicacy and dexterity is achieved. Modern robotic systems fall into three categories; active, semi-active and master-slave.But the most commonly used are master-slave systems distinguished by the surgeon’s absolute control of the robot via a remote control console.

The Da Vinci is a sophisticated master-slave robot that incorporates 3-D high definition visualization, scaling of movement, and wristed instrumentation. The operations with the Da Vinci System are performed with no direct mechanical connection between the surgeon and the patient. The surgeon is working a few feet away from the operating table, while seated at a computer console with a three-dimensional view of the operating field.

Robotic Prostatectomy, also known as Robotic surgery for prostate cancer or da Vinci Prostatectomy is a minimally invasive surgery that is now the preferred approach for removal of the prostate in those diagnosed with organ-confined prostate cancer. The da Vinci Prostatectomy may be the most effective, least invasive prostate surgery performed today. Though any diagnosis of cancer can be traumatic, the good news is that if your doctor recommends prostate surgery, the cancer was probably caught early. And, with da Vinci Prostatectomy, the likelihood of a complete recovery from prostate cancer without long-term side effects is, for most patients, better than it has ever been.

The operation is performed using the daVinci Surgical system and 3-D endoscopic and wristed instruments inserted through 5-6 small incisions across the mid-abdomen

Advantages of Robotic prostatectomy

• Minimal Bleeding Faster return to normal daily activities .
• Reduced hospital stay Significantly less pain and scarring
• Lower blood transfusion rates
• Improved preservation of physical appearance.
• Three (3) D vision enables surgeon to perform Prostate excision with Cancer.
• Lower blood transfusion rates
• Control without risk of Post Surgery Continence (control over urinary and fecal discharge) and causing Impotency

Scope of Robotic assisted Laparoscopic surgery in Urology

• Prostate Cancer- Robotic Radical Prostatectomy
• Pelvi-Ureteric Junction (PUJ) Obstruction- Robotic Pyeloplasty
• Kidney Tumors- Robotic Partial Nephrectomy
• Bladder Cancer- Radical Cystectomy
• Ureteric Reimplantation
• Pelvic Tumor Excision

Percutaneous Nephrolithotomy (PCNL) is a procedure to remove medium-sized or large stones from the kidney by means of a nephroscope passed into the kidney through a small puncture created in the patient’s back. A nephroscope uses an ultrasonic or laser probe to break up large kidney stones and suction it out. This procedure is usually done under general anaesthesia or spinal anaesthesia.

To undergo PCNL, it is ideal for the patient to have two functioning kidneys and large sized (2 cm) stone in one of the kidneys with extrarenal pelvis with mild to moderate hydronephrosis.

The advantage of the PCNL procedure as against an open surgery is that PCNL reduces the length of hospital stay, and leaves only a small stab wound scar. Also during the post-operative period, a negligible amount of pain is felt allowing the patient to recover faster.

The surgical application of robotic systems is one of the most exciting and significant technological developments of this century; its future implications are incalculable.Huge strides have been made in the field of closed operations in the past 10 years and the use of robotic systems has emerged as the principle solution to technical limitations

How is the Percutaneous nephrolithotomy (PCNL ) Surgery performed?

While you are under the general anaesthetic the surgeon will examine your bladder with a long, thin, semi-rigid or flexible telescope and pass a small tube up to your kidney, which has the stone. This is used to pass a mixture of a coloured dye and x-ray dye to the kidney making it easier to see during the operation.

You will then be placed face down on the operating table and the consultant will make one or more small incisions into your back. This is done using special metal or balloon dilators (see diagram). This enables the consultant to pass a telescope into your kidney.

The stone or stones in the kidney are then removed either intact or in pieces after breaking them with special instruments. X-rays will be taken during and at the end of the procedure to ensure that all accessible bits of the stone have been removed from your kidney.

A telescope is passed down into the kidney so that the surgeon can see the stone.

The stone is broken up and then the pieces are removed using a special instrument.

Why is Percutaneous Nephrolithotomy (PCNL) Necessary?

You have been diagnosed as having a kidney stone (or stones) causing some, or all, of these symptoms: pain, infections, bleeding or obstruction of your kidney, which if left untreated, may lead to further symptoms or complications, such as severe infection or loss of kidney function. This operation (PCNL) is performed to remove large kidney stones using a keyhole approach. This is a major operation despite the term ‘keyhole surgery’. The procedure requires a general anaesthetic and may last 1 to 3 hours with a hospital stay from 4 to 7 days. The success rate of kidney stone clearance ranges from 75% to 100% depending on various factors.

What are the Advantages Percutaneous Nephrolithotomy (PCNL)Surgery

• Mini – invasive operation, less pain, short hospital stay (3 or 4 days), quick recovery and early return to work (7 to 10 days)
• Avoid a surgical scar, meaning that avoids the complications of a large incision to remove the kidney stone
• Limit residual stone. This is the special advantage of PCNL over other intervention due to its possibility to look inside the ureter and renal calyx to check which may not always be done by open operation and ESWL procedure.
• Minimize the occurrence of postoperative infections (compared with open surgery).
• Less harm to the kidney function (the influence of PCNL on kidney function is smaller than 1% while open surgery may cause the loss of 30% kidney function due to the incision made on renal parenchyma).

Kidney stones are also known as calculi (plural), or calculus (singular). When it is in the kidney, it is a renal calculus. The tube draining the kidney to the bladder is the ureter, and a stone in the ureter is a ureteral calculus. It is estimated that 20% of us will have a kidney stone in our lifetime. Of those who get a stone, 50% will recur. Passing a stone is usually very painful. However, many patients can pass a stone with only a “muscle ache” sensation in the back, and they may not be aware the pain was from a stone until it “pops out.”

How are kidney stones diagnosed?

When a urinary stone is suspected, an immediate evaluation is required. Blood is obtained to check on overall kidney function as well as to exclude signs of infection throughout the body. Urine is sent for a urinalysis and culture, also to examine for infection. A simple X-ray of the abdomen is sometimes enough to pinpoint a calcification in the area of the kidneys or ureters, thus identifying a likely obstructing stone. However it is sometimes difficult to determine if the calcification is within the urinary tract and also some stones are not radiopaque. Historically, an intravenous pyelogram (IVP) was done, but today computed tomography (CT) is the gold standard for stone diagnosis as it is very sensitive and can detect almost all types of urinary stones.

Extracorporeal shock wave lithotripsy (ESWL) is the most frequently used procedure for the treatment of kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into small particles and are easily passed through the urinary tract in the urine.

Several types of ESWL devices exist. Most devices use either x-rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, anesthesia is needed.

Percutaneous nephrolithotomy (PNL)

PNL is the treatment of choice for large stones located within the kidney that cannot be effectively treated with either SWL or URS. General anesthesia is usually required to perform a PNL. The main advantage of this approach compared to traditional open surgery is that only a small incision (about one centimeter) is required in the flank. The urologist then places a guide wire through the incision. The wire is inserted into the kidney under radiographic guidance and directed down the ureter. A passage is then created around the wire using dilators to provide access into the kidney.

An instrument called a nephroscope is then passed into the kidney to visualize the stone. Fragmentation can then be done using an ultrasonic probe or a laser. Because the tract allows passage of larger instruments, your urologist can suction out or grasp the stone fragments as they are produced. This results in a higher clearance of stone fragments than with SWL or URS.

Ureteroscopic Lithotrispy with Holmium Laser

Holmium Laser lithotripsy is the breaking of urinary stone using the Holmium laser. The wavelength is ideal for treating stones. The Holmium laser energy may be absorbed by the stone creating cracks within the stone. This laser energy is sufficient to break even the hardest stone.

The Holmium laser energy is delivered via thin fibers with various diameters to suit telescopes of different sizes. These telescopes may be rigid, metal telescopes or flexible fibreoptic type. This thin telescope called a ureteroscope is passed gently and skillfully through the natural urinary passage from the penis up the bladder into the ureter where the stone is. This procedure is called ureteroscopy. The Holmium laser fiber can be placed in contact with the stone or adjacent to it. Short Holmium laser pulses create a shockwave that causes fragmentation of the stone. Smaller stones can be fragmented directly, whereas with larger ones, holes are punched in the center, after which the edges are chiseled away with the Holmium laser. Finally, the residual fragments can be flushed out.

Robotic Heart Surgery are now widely used to provide patients with less pain and faster recovery time. Limitations in surgical equipment have prohibited their use during heart bypass surgery — until now.

The advancement of computerized robotic technology is one of the most exciting breakthroughs in surgery to date, enabling surgeons to perform complete, bypass surgery less invasively. Penn Cardiac Care at the Hospital of the University of Pennsylvania is proud to be the only hospital in Philadelphia and one of only 12 in the nation invited to participate in a study to determine the effectiveness of this revolutionary procedure.

Robotic Heart Surgery in India is the latest and most advanced technique in the world to perform heart surgery with greatest precision Robot Assisted Heart Procedures are done to treat a variety of conditions:

• Mitral valve repair—surgery to repair problems with the valve between the upper and lower chambers on the left side of the heart
• Coronary artery bypass grafting (CABG)—surgery that creates a path around blocked heart vessels so that blood can reach the heart muscle. The bypass is done using blood vessels from other parts of the body

Da Vinci Robotic System

Only da Vinci overcomes the limitations of both traditional open surgery and conventional minimally invasive surgery. The da Vinci System is a sophisticated robotic platform designed to expand the surgeon’s capabilities – and for the first time – offer a minimally invasive option for major surgery.

With da Vinci, small incisions are used to introduce miniaturized wristed instruments and a high-definition 3D camera. Seated comfortably at the da Vinci console, your surgeon views a magnified, high-resolution 3D image of the surgical site. At the same time, state-of-the-art robotic and computer technologies scale, filter and seamlessly translate your surgeon’s hand movements into precise micro-movements of the da Vinci instruments.

The System cannot be programmed, nor can it make decisions on its own. Rather, the da Vinci System requires that every surgical maneuver be performed with direct input from your surgeon.

Heart Surgery procedures where Robotic Heart Surgery can be used

Robot Assisted Mitral Valve Repair may be used to treat

• Blockages in the heart’s arteries
• Severe chest pain ( angina ) that has not improved with medicines

Robot-assisted Atrial Septal defect repair may be used to treat a hole between the upper chambers of the heart that does not close properly during foetal development.

Robot-assisted Biventricular Pacemaker lead placement may be used to treat heart failure due to Atrial Fibrillation (irregular heart rhythm in the upper chambers of the heart)

What are the advantages of robotic heart surgery?

The chief advantage of such surgery is that the incisions that are made are tiny, and therefore recovery from surgery is extremely quick. Rapid recovery from cardiac surgery is not only better for the patient, but it is less expensive for society.