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.
- 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
- 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 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
- 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
- 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
- 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
- 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
- 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
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
- In 2014 the record for the largest chain was broken again by a swap
involving 70 participants.
- 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
- Kidney is harvested with renal artery, renal vein
And large segment of ureter also
- Usually done by urologist & general surgeon
- 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
- 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