Dr. Tanuj's Urology Clinic

Hello!

I am Dr. Tanuj Paul Bhatia, In my earlier video, I had spoken about the different symptoms of kidney stones and prostate diseases and just touched upon the different types of treatments that are available. Today we will talk about the different type of treatment which is available for the treatment of kidney stones apart from conservative management. Conservative management means when we have small stones and non-stones, we treat the patients with medicines so that which helps the stones to pass out. But when the stones stay for a long time, say more than three to four weeks or if they cause any complication like if they cause fever, if they cause derangement of the renal function or if the stone is very big then we need to take it out. Of course, the type of treatment that we administer depends on a couple of things. So how we decide about that is the first thing that we look at is what is the site of the stone. So, the site of the kidney stone can be right there in the kidney, it can be in one of the calyces or in the pelvic part of the kidney or in the ureter or lower down; so, depending on the site of the stone the treatment varies. So, as we talk about the different treatment options first, we will talk about the least invasive and then the most invasive type of treatment. So, the least invasive treatment of kidney stone is by extracorporeal shock wave lithotripsy which is routinely referred to as lithotripsy treatment by the general public.

So, what this involves is that the patient has to lie down in this couch and there are rays which are targeted on to the stone from outside the body and which help the stone to break. This was earlier a quite popular modality of treatment, however, in case of lithotripsy most of the patients if the stone is large, they require multiple sittings and sometimes if the stone is very hard the machine is not able to break the stone. So gradually the popularity of this particular technique has gone down but still, it is reserved for certain stones like soft stones or especially for stones in case of paediatric population that is children. Next commonly done surgery for stone is URS or Uretero renoscopy. So, it depends on the site of stone which type of uretero renoscopy we are doing. If the stone is in the ureter, that is the tube draining urine from kidney to bladder then we use a semi-rigid ureteroscope which is commonly referred to as URS. If the stone is in the upper part of the ureter or somewhere in the kidney then we use a flexible uretero renoscope, this is commonly referred to as RIRS or retrograde intra-renal surgery.

This is a quite popular modality of treatment nowadays because this involves treatment of the stone through the normal urinary passage, there is no cut made on the body and we are able to treat the stone right from below the normal urinary passage, we are able to go right up to the kidney and we treat the stone there with laser, so we break the stone with laser and we take out the larger particles out with baskets like this and that is how we help the patient to become stone free. Also, we break the stone into very small particles and the so that they can pass out through the normal urinary passage. When the stone is in the kidney or in the upper ureter another famous modality of treatment is percutaneous nephrolithotomy or PCNL. In PCNL, we make a small cut at the back and we make the track that is we drill hole into the kidney and we make this track and then we pass the endoscope from the skin into the kidney and we break the stone here and we take it out. The routine PCNL involves the larger size track however with time there has been technological advancement and now we have what is referred to as mini PCNL in which we use a relatively smaller sheath. This leads to lesser risk of bleeding from the kidney parenchyma and we are able to clean treat the stone with laser and we take out the particles from the kidney. To benefit of PCNL over RIRS is that all the fragments are extracted in the same sitting usually. Another new modality which has now come up is supine PCNL.

Although, this is reserved strictly for patients in whom we need to treat either multiple kidney stones or kidney with uretery stones or in very obese patients or in patients with skeletal anomalies in whom positioning in prone position is difficult. But this now this technique now becomes very popular in European countries and it is picking up fast and in future, this might be the way we would be doing all our PCNL's as well. Then another advantage that supine PCNL offers us is that we are able to approach the kidney from below that is to the ureter as well as from the back, so earlier if there are stones in multiple different calyces in the kidney, we had to make multiple punctures in the kidney. Now with the help of this technique we need not make multiple punctures, we can enter the kidney through one puncture then we can pass our flexible ureteroscope into different calyces, we break the stone there and we pass it out through this track from the back, this is referred to as passing the parcel technique and the technique is called ECIRS or endoscopic combined intra-renal surgery.

Laparoscopic surgery which involves 3 or 4 cuts on the abdomen and then taking out the making a cut on the kidney and taking out the stone is not a very popular modality of treatment for kidney stones and it is reserved for very rare cases like anomalous kidneys. Although with advancement, now we are able to do stones and operate on stones in anomalous kidneys also with techniques like RIRS. So that was about the different operative techniques for kidney stones and uretery stones. The era of open surgery for stone is now almost gone. Very rarely it is that we have to make a large cut on the abdomen to take out a stone nowadays.

Thank you!

Hello Everyone,

I am Dr. Tanuj Paul Bhatia, urologist at Sarvodaya Hospital, Faridabad. Today we will talk about benign enlargement of prostate which is affecting at old age. Prostate gland is a walnut-shaped gland which is in our body and we pass urine through prostate which comes out through urethra. When prostate gland increases in size with age, it causes some sort of infection to the flow of urine and that is when the patient develops the symptoms of prostate enlargement. Some patient also feels the urgency to urine. The most common symptoms of the disease are poor flow of urine. They also develop intermittency i.e. urine does not pass out in one stream. The patient wants to pass urine but he is not able to pass the same and he has to wait. When patient feels to urinate, they have to rush to the bathroom and if they ignore or hold it back they may develop urine incontinence. Patient may also suffer from the increased flow in urination. Patient may also suffer from the problem of blood in urine i.e. called hematuria. It should trigger complete evaluation of the patient. When the patient comes to us with these symptoms, we examine the patient with these symptoms.

Urinary symptoms also referred to as lower urinary tract symptoms. After complete history and examination, we move on to investigation. So, we start the treatment with ultrasound. Some diabetic patients may not know that they are holding urine back in the bladder. Blood test for prostate enlargement is kidney function test, prostate-specific antigen (PSA) test. This includes infection of prostate or prostatitis, prostate cancer. So, PSA is used as a screening test. There is a test in which patient is asked to pass urine in a special commode which is connected with the computer through which we can check the flow of the urine. Other than that we also get a urine routine and urine culture test done for all those patients who come to use with urinary symptoms.

At times we see that patient does not have any symptoms but when ultrasound is done, we see a problem in the prostate. When symptoms are bothersome, that is when you require treatment for prostatic enlargement. Few patient require surgery for the same. We use different types of drugs to treat this problem. Patient develops prostate as well as erectile dysfunction problem. When we talk about the surgery so, those days are gone when big surgeries where happening. Now the prostate is operated with endoscopically through the urinary tract. Any size of the prostate can be taken out with this procedure. 2 main techniques are used fo this procedure. One is electrocautery and it is referred to as TURP (transurethral resection of the prostate) and another method is used called laser (laser prostatectomy).

How to know you require surgery or not? If you are not responding to the medications at all, you require surgery. If you are responding to the medicines and not having satisfactory result, you need surgery. If you develop recurrent urinary tract infection because of prostatomegaly than you require surgery. If you develop recurrent bleeding in urine i.e. hematuria, you do require surgery. In addition to these, some patient develops stones in bladder because of blockage in urine due to prostate, those patients are straight away the indications of surgery. If the disease is neglected for a very long time, the patient may develop kidney disease i.e. a renal failure. So, 2 types of surgeries are there. Both are done through endoscopy without any cuts. Most common surgery is TURP. In this technique, electrocautery is used and with the small cuts we push into the bladder and then they are taken out. It is a technique which is there for very long.

It is a time tested technique. It has very good results. However, if the prostate is very large and patient is taking medicines for blood thinner which is very common and used for coronary artery diseases so, these patients have the risk of bleeding. They have the risk of excessive bleeding during the treatment. That is why they benefit from laser prostatectomy. Also, with TURP there used to be a risk of dilutional hyponatremia which is referred to as TORRE syndrome. With the laser treatment, the risk of TORRE syndrome is very less. So, the advantage of laser prostatectomy is in the patient with large prostate, in patients who are on blood thinner and in patients with chronic disease.

Thanks!

Hi!

I’m Dr. Tanuj Paul Bhatia, senior consultant of urology at Sarvodya hospital, Faridabad.

So I will discuss what is urology? And mainly about kidney stones today. Urology is a branch of medicine which deals with male and female urinary tract and male reproductive organs. Basically in this we deal with the kidneys, where it is formed and then it comes to ureter and through the ureter it comes to the bladder and then it does empties through urethra and comes out of the body. So this is our entire urinary system and the diseases of this entire system is dealt by urologist i.e. us. So when we come to kidney stones we know that kidney stone is a very common disease, it is highly prevalent in almost whole of entire north India and states like Punjab, Haryana, Delhi and Rajasthan. They form part of stone built of India and stone built of the world. That is mainly because in this regions the temperatures are very high mainly due to summers and water consumption is not enough and most of the people tend to be dehydrated which is also occurring in the formation of kidney stones. Now if we come to etiology of kidney stone that is why our kidneys stones formed? In some people it is because the condition is genetic, they have parents or grandparents who were the stone former so the genes are passed on and they have the tendency of formation of stones. Sometimes there are patients who have other diseases which can lead to stone formation or sometimes during treatment e.g. some forms of bilateral surgery or excessive dieting can also lead to the formation of kidney stones most of the patients, however, do not have a specific reason of stone formation and they are etiologic stone formers. When it comes to symptoms of kidney stones, most common symptoms of kidney stone is pain and the pain is very typical, patients usually typically complain of back pain which rotates either from back to front or lower part of abdomen or from lower part of abdomen to the back. And sometimes male can experience pain in the scrotum and females can experience pain in the vulva region as well because of the kidney stone when they are obstructing. Having said that it is rather ironical sometimes bigger stones can actually be asymptomatic and detect on investigations done on the other purposes. So when it comes to diagnosis of kidney stones most useful entity to us for diagnosis is ultrasound.

Ultrasound is a non-invasive test and it offers them as a screening test. For urologist it is a examination of a clinical examination, it is the extension of the clinical examination. So most of the times stones are identified on ultrasound and when required we do the CT scan to further confirm the size and location of kidney stone as well as the density i.e. how hard is that stone. And these tool examination mainly form are basic outcomes. So when it comes to treatment of kidney stones the treatment of kidney stones depends on the size of the kidney stones, the location of the kidney stones and whether it is causing any complications. So when we talk about size it has been seen in most of the studies that stones that are lesser than 6mm have good chance of passing out by itself. So we always try conservative approach for these patients and we keep them on medications. Most of the patients that is about 80-90% of the patients who develop the pain due to stones have small stones and they do not require any surgery and they will pass out the stones with themselves with some additional medicines which will keep them pain free and their ureter to relax and in turn helps the stone to pass out themselves. When the stones is bigger than 6mm the chances of passing out spontaneously decrease. As the sizes increases further the chances decreases further. Similarly if the stone is tuck in the upper part of the urinary tract the chances of passing out spontaneously are less however if the stone is tuck in the lower part of urinary tract the chances of passing spontaneously is good. So third thing is complications, so whenever there is stone and it is causing recurrent urinary tract infection or it is causing fever or it is cause disengagement of the renal functions then it requires urgent treatment and it has to be removed. When we talk about surgeries of kidney stone there are different types of surgeries. So when the stone is in the kidney itself basically we can do 3 types of surgeries. One is ESWL or lithotripsy. In ESWL the patient is made to lie on a bed and some shock waves are applied to this part of the abdomen and they help the stones to break. However disadvantages of ESWL is that the success rate is relatively poor when compared to other modalities and they usually requires repetition.

So then came the era of PCNL. PCNL is the procedure which is called as percutaneous nephrolithotomy. In this the hole is made at the back and into the kidney and endoscope is passed into the kidney and stone is broken and removed. So it is a very good techniques but nowadays it is prefer only for very large stones and the latest technique in treatment of kidney stones is RIRS which is retrograde intrarenal surgery. In RIRS we basically go through a normal urinary tract and that is we go through the urethra up into the bladder and through the ureter we go into the kidney. And with this flexible urethroscope we break the stone there and there in the kidney itself, we make it into a very fine dust like substance and then we put it in a stand and come out. So most of the time this dust clears has ureter dilates because of the strand. However it has its own limitations specially when there is a very large stone e.g. stones larger than 2cm you may require multiple sitting of RIRS but for stones less than 2cm RIRS is now the preferred procedure. It is also preferred when the kidney is located in the abnormal position like in the pelvis or it is the malrotated kidney because when the kidney becomes difficult to approach via other modalities and but flexible endoscopy or RIRS we can reach it and we can break the stone then and there. When it comes to stone in ureter there are 2 modalities that are used to treat.1 is ureteroscopy which is a straight reject stereoscope and it is used to access the ureter and the stone is broken and removed. When the stone is in the upper part of kidney again there is a high chance of reproduction. Retrobuction is passing out the stone back into the kidney so if it is going back into the kidney the advantages of RIRS comes in, we can pass the flexible ureteroscope through the same route going into the kidney and break the stone which is retro pass back into the kidney. When it comes to bladder stones there are 3 procedures which are done one is cystolitholapaxy, then cystolithotripsy, and percutaneous cystolithotripsy. It depends on the size of the stone that which procedure will be done. If the stone is not very big it can be crush using a special forceps which is called as cystolitholapaxy. If the stone is between 1-5 cm then it can be broken through the normal urinary tract to transvaginal cystolithotripsy. If the stone is very big a small tract is made in the upper pelvic area and the stone is fragmented and removed.

Thank you!