CANCER OF THE URINARY BLADDER

Bladder cancer accounts for approximately 90% of cancers of the urinary tract (renal pelvis, ureters, bladder, urethra). The bladder is an organ located in the pelvic cavity that stores and discharges urine. Urine is produced by the kidneys, carried to the bladder by the ureters, and excreted from the bladder through the urethra.

Bladder cancer usually originates in the bladder lining, which consists of a mucous layer of surface cells called transitional epithelial cells, smooth muscle, and a fibrous layer. Tumors are categorized as low-stage (superficial) or high-stage (muscle invasive).

More than 90% of cases originate in the transitional epithelial cells (called transitional cell carcinoma; TCC). Then next most common type is squamous cell carcinoma caused by Schistosoma haematobium (parasitic organism) infection and is often times associated with a long standing urinary bladder stone. Rare types of bladder cancer include small cell carcinoma, carcinosarcoma, primary lymphoma, and sarcoma.

Incidence of bladder cancer increases with age. People over the age of 70 develop the disease 2 to 3 times more often than those aged 55–69 and 15 to 20 times more often than those aged 30–54.
Bladder cancer is 2 to 3 times more common in men. Bladder cancer is the fourth most common type of cancer in men and the eighth most common type in women.

CAUSES AND RISK FACTORS
Cancer-causing agents (carcinogens) in the urine may lead to the development of bladder cancer. Cigarettte smoking contributes to more than 50% of cases, and smoking cigars or pipes also increases the risk.

Other risk factors include the following:

• Age
• Chronic bladder inflammation (recurrent urinary tract infection, urinary stones)
• Consumption of Aristolochia fangchi (herb used in some weight-loss formulas)
• Diet high in saturated fat
• Exposure to second-hand smoke
• External beam radiation
• Family history of bladder cancer (several genetic risk factors identified)
• Gender (male)
• Infection with Schistosoma haematobium (parasite found in many developing countries)
• Personal history of bladder cancer
• Treatment with certain drugs (e.g., cyclophosfamide—used to treat cancer)

Exposure to carcinogens in the workplace also increases the risk for bladder cancer. Medical workers exposed during the preparation, storage, administration, or disposal of antineoplastic drugs (used in chemotherapy) are at increased risk. Occupational risk factors include recurrent and early exposure to hair dye, and exposure to dye containing aniline, a chemical used in medical and industrial dyes.

Workers at increased risk include the following:

• Hairdressers
• Machinists
• Printers
• Painters
• Truck drivers
• Workers in rubber, chemical, textile, metal, and leather industries

SIGNS AND SYMPTOMS

The primary symptom of bladder cancer is blood in the urine (hematuria). Hematuria may be visible to the naked eye (gross) or visible only under a microscope (microscopic) and is usually painless.
Other symptoms include frequent urination and pain upon urination (dysuria).

DIAGNOSIS

Diagnosis of bladder cancer includes urological tests and imaging tests. A complete medical history is used to identify potential risk factors (e.g., smoking, exposure to dyes).

LABORATORY TESTS

• Urinalysis (to detect microscopic hematuria)
• Urine cytology (to detect cancer cells by examining cells flushed from the bladder during urination)

IMAGING TESTS

Ultrasound

This is the initial test performed and most patients come to the urologist with an ultrasound report.

Computed Tomography

More and more frequently computed tomography (CT) without and with intravenous contrast has replaced intravenous pyelography (IVP) the evaluation of hematuria. With computer-assisted reconstruction, longitudinal views of the urinary tract can now be made, although their sensitivity in detecting small or flat tumors of the urothelium is limited.

Intravenous Pyelography

If CT is not performed, IVP is indicated in all patients with signs and symptoms suggestive of bladder cancer. Urography is not a sensitive means of detecting bladder tumors, particularly small ones. However, it is useful in examining the upper urinary tracts for associated urothelial tumors. Large tumors may appear as filling defects in the bladder on the cystogram phase of the urogram. Ureteral obstruction caused by a bladder tumor is usually a sign of muscle-invasive cancer. Additionally, of course, IVP can assess other upper tract abnormalities that may affect management decisions.

Treatment
Treatment for bladder cancer depends on the stage of the disease, the type of cancer, and the patient's age and overall health. Options include surgery, chemotherapy, radiation, and immunotherapy. In some cases, treatments are combined (e.g., surgery or radiation and chemotherapy, preoperative radiation).

Cancer of the Kidney

There are several types of cancer found in the kidneys. Renal cell carcinoma (RCCA), the most common form, accounts for approximately 85% of all cases. In RCCA, cancer (malignant) cells develop in the lining of the kidney's tubules and grow into a tumor. In most cases, a single tumor develops, although more than one tumor can develop within one or both kidneys.

Early diagnosis of kidney cancer is important. As with most types of cancer, the earlier the tumor is discovered, the better is the patient's chances for survival. Tumors discovered at an early stage often respond well to treatment. Survival rates in such cases are high. Tumors that have grown large or spread (metastasized) through the bloodstream or lymphatic system to other parts of the body are more difficult to treat and present an increased risk for mortality.

Studies have shown that certain lifestyle factors can increase the risk of developing kidney tumors. Smoking, having high blood pressure, eating a high-fat diet, and being overweight all may contribute to an increased risk of kidney cancer.

RISK FACTORS

Although we do not know all the causes of kidney cancer, the following factors can also increase the risk of developing this disease:

* long-term dialysis, a process in which a machine filters the blood of a person without functioning kidneys

* exposure to asbestos, such as occupational exposure

* exposure to cadmium, a metal that can increase the cancer-causing effect of smoking

* a family history of kidney cancer

* von Hippel-Lindau disease, a syndrome caused by a genetic mutation that leads to multiple tumors in the kidney, often at an early age

* tuberous sclerosis, a disease characterized by several bumps on the skin, seizures, mental retardation, and cysts in the kidneys, liver, and pancreas

SYMPTOMS

Kidney cancer usually shows no symptoms in the early stages. It is generally not suspected until the patient begins to experience symptoms, and at this point the tumor may have grown fairly large.

As the cancer progresses, symptoms may include some of the following:

* Abdominal mass or lump
* Blood in the urine (hematuria)
* Fever
* High blood pressure (hypertension)
* Pain in the side (flank) or lower back not associated with injury
* Persistent fatigue
* Rapid, unexplained weight loss
* Swelling (edema) in the legs and ankles

DIAGNOSIS

Blood tests :
1) CBC
3) Creatinine
3) Calcium

Imaging tests:

1)Ultrasound

2)CT Scan/MRI



STAGING



TREATMENT

Surgery is the standard treatment for RCC. There are several surgical options, depending on the stage of the disease and the overall health of the patient.

Partial Nephrectomy: Kidney-Sparing Surgery

Kidney-sparing (or nephron-sparing) surgery is the term used to describe the procedure in which a kidney tumor is removed, leaving a margin of normal kidney tissue in order to preserve the function of the remaining kidney. Studies have demonstrated that partial nephrectomy yields comparable results to complete nephrectomy in patients with small tumors (less than 4 centimeters), while maintaining functioning kidney tissue.

Radical Nephrectomy

In some situations, the entire kidney needs to be removed. Tumors that require complete nephrectomy tend to be larger in size and to have advanced locally, though sometimes they have spread to another part of the body. This procedure can be done by the open or laparoscopic approach. Because we are able to offer all possible modes of treatment, we can tailor the approach to each individual patient.

The advanced Minimally Invasive Surgery in Mindanao

The establishment of the state-of-the art center of Minimally Invasive Surgery (MIS) in Mindanao intensifies the evolution of open surgery.

The evolution of open surgery paves way to fewer invasions of human body. However, specialists can still generate quality result at a more precise manner.

The MIS employs video cameras and lens system to provide anatomic visualization using the laparoscopic/endoscopic instruments for diagnostic/ therapeutic intervention

The MIS center of DMSF Hospital has the following sections: General Surgery, Urology, Colorectal, Gastroenterology, Gyne, Orthopedic, ENT, Thoracic and Bronchoscopy.

The movers behind this revolution are trained locally and internationally.

The DMSF Hospital like any other hospitals worldwide joins in the innovation of surgical practice wherein less tissue trauma, scars and greater recovery of tissue at a more painstaking effort.

Patients can expect a more quality of alternate open surgeries at an affordable and less invasive delivery of minimally invasive surgery yet the culture of trust and utmost care is strongly practiced.

from DMSF Hospital website: http://www.dmsfhospital.com/

That Same Old Feeling

Last June 20, I had a procedure at DMSF Hospital. My patient had an obstructing 1.8 cm ureteral stone on the left noted on ultrasound and his creatinine was already elevated. However, it was not seen on the plain KUB xray. Good, since the option of dissolving the stone through medication would work for this patient meaning that I dont have to open him up. He was not a regular patient since he was diabetic, hypertensive and in heart failure! Not to mention, he is the father of a grade school classmate, brother of one of my mom's amigas and a fellow Batangueno-Davaoeno. Usually, I don't give in to this kind of pressure but honestly, I felt quite uneasy but still focused. He was cleared for surgery and it was the first time that I did a surgery with the cardiologist requesting that the cardiovascular anesthesiologist be the one to induce anesthesia. I had no qualms regarding that since it was all for patient safety, and I know that he will be in good hands. I did a cystoscopy, retrograde pyelography which showed a radiolucent 1.5 cm, partially obstructing proximal ureteral stone. Luckily, I was able to bypass the stone and insert a double J stent. When I talked to the family after the procedure, I could see their relief after knowing I that I didn't have to do an open procedure. I, too, was relieved because as much as possible, opening him up was last on my list. God was on my side that day!

My patient had a follow up check up a week (June 27) after I put in the stent, His creatinine went down to 1.3 mg/dL from the elevated 2.9 mg/dL preoperatively. I could feel his happiness with the outcome of the procedure. I received endless words of gratitude which made me feel good. He returned to work a few days after he was discharged from the hospital. His co-workers were curious about what procedure was done and how was it done. He even told me: "Doc, don't worry, people will start coming here, I told them to see you if they have any problems with regards to your specialty."
Thanks! Instant advertisement for me.

Its different when I was still in training since most of the patients that I handled had a purely doctor-patient relationship. I have this nice and light feeling everytime I my patients and relatives express their gratitude especially after a successful surgery.

I had the same nice and light feeling since I was able to do good to someone who is not only a patient but also is considered a friend of the family.

Conked Out...

RENAL FAILURE

Acute Renal Failure

Acute renal failure (ARF) is a condition of abrupt deterioration in renal function as evidenced by rising blood urea nitrogen (BUN) and creatinine levels. It is usually associated with decreased urine output. Approximately occur in the surgical setting and early recognition can minimize the extent of renal injury. It is classified under 3 categories: prerenal, postrenal and intrarenal.



Prerenal azotemia is caused by the direct result of inadequate renal blood flow. If the cause for the poor blood flow can be reversed then the problem can be resolved. However, prolonged low flow states can produce ischemic kidney injury.

Causes of Prerenal azotemia:

1) Volume depletion – hemorrhage, dehydration
2) Low cardiac output – congestive heart failure, cardiogenic shock)
3) Renal artery (stenosis, occlusion, vasoconstriction)
4) Systemic vasodilatation (sepsis, anaphylaxis, overdose)

Postrenal azotemia is caused by obstruction to urine flow. Pressures in the renal collecting system and tubules rise with obstruction causing renal injury if the obstruction is not relieved.

Causes of urinary obstruction:

1) Bladder outlet – enlarged prostate, urethral stricture, bladder stones, foreign body, tumor, blood clot)
2) Ureter – stones, tumors, stricture, stenosis

Intrarenal

Acute parenchymal renal failure is the result of damage to the renal tubules brought about by inflammation, injury from substances toxic to the kidney (nephrotoxic) and decreased blood flow.

Causes of intrarenal failure

1) Acute tubular necrosis (ATN) – 3 phases: 1) onset 2) oliguric 3) postoliguric. The oliguric period (urine output less than 500cc/day) typically lasts for 10-14 days but may be as brief as 2 days or as long as 6-8 weeks. A non-oliguric ATN can occur when it is secondary to nephrotoxic injury for ex from certain drugs or substances.

Causes of ATN

a) Ischemic injury – hypotension, cardiogenic or septic shock
b) Nephrotoxins – aminoglycosides, anesthetic agents, iodinated contrast media, NSAIDS
c) Hemoglobinuria (hemoglobin in the urine) or myoglobinuria (muscle cells in the urine)

2) Acute glomelular nephritis (AGN)

3) Acute interstititial nephritis (AIN)

The work up of a patient with sudden elevation of BUN and creatinine, with or without decreased urine output requires a prompt, systematic approach to exclude any reversible pathophysiologic states and remove any potentially nephrotoxic agents. Prerenal and postrenal causes must be excluded before diagnosing intrinsic renal disease.

CHRONIC RENAL FAILURE

Chronic renal failure (CRF) is caused by a spectrum of diseases resulting in progressive irreversible loss of functioning nephrons ultimately leading to end stage renal disease (ESRD) requiring dialysis or transplantation. The most common causes include:

1) Diabetes mellitus
2) Hypertension
3) Primary and secondary glomerular disease
4) Hereditary renal disease
5) Obstructive uropathy
6) Chronic infection
7) Interstitial nephritis

A wide variety of systemic symptoms are seen and there is a multisystem involvement making management difficult. Symptoms include:

1) Electrolyte imbalance –decreased phosphates, increased potassium
2) Gastrointestinal – nausea, vomiting, anorexia
3) Hematologic –anemia, platelet dysfunction
4) Neurologic –neuropathy, encephalopathy
5) Cardiovascular – increased severity of atherosclerosis, prolonged hypertension
6) Endocrine – abnormal bone metabolism, glucose intolerance
7) Sexual dysfunction

The general management of patients with CRF centers on slowing the progression of functional renal deterioration. There is no effective treatment for most glomerulopathies. Any reversible or controllable factors must be addressed. Once the glomerular filtration rate deteriorates to levels that produce symptoms of ESRD, then dialysis or transplantation becomes the only option

A Different World

Fresh from my urology training at National Kidney and Transplant Institute, I arrived in Davao City on the last week of January 2008. After complying with the requirements, I started private practice sometime mid February. Quite a struggle, I was out of touch with my medical and non-medical circle of friends, only a handful knew that I was back. Thanks to supportive colleagues and friends, I was able to inch my way slowly into the world of private practice. No one said that its gonna be a walk in the park. Especially if there are people who make you make things harder for you. I had a difficult time adjusting to this slow pace since I trained in a high volume institution wherein surgeries are done day in and day out.
The tide has changed, when I arrived in NKTI, I asked myself if I was ready for the fast pace life in the capital, now I found myself asking me again if I was ready to go back to the laid back lifestyle in Davao. After staying in Manila for the past 4 yrs, I was accustomed to the pace and lifestyle there, especially in the workplace.
In my line of work, efficiency is of the essence, so I hate it so much if there are problems caused by inefficiency of the staff. I also am systematic in things that I do especially with my surgeries. I get upset if there would be delays because of poor preparation of supplies and/or instruments. Well, I guess that I have to extend my patience more since most people here are not used to the usual "toxic" that is considered a way of life in other places. Call me strict or toxic, but I have a systematic and efficient way of doing things so that no effort is wasted (Toxic- a hospital slang used for busy; strict person. During training, the toxic persons were the residents and fellows especially the seniors. Why? Its something that cant be explained in words but could be understood by people who were once residents and fellows.)
I'm in a different world right now, a place where I'll be in the years to come. No one said that it's gonna be easy, but I know that it's gonna be worth it.

MY Workplaces

DAVAO MEDICAL SCHOOL FOUNDATION HOSPITAL, BAJADA, DAVAO CITY


RIVERA MEDICAL CENTER, INC, PANABO CITY

NEW GROWTHS

A neoplasm is an abnormal or new growth of tissues. This may be benign, which means that there is an abnormal growth pattern and on the other hand, malignant which is characterized by an uncontrolled cell division with the ability of these cells to invade other tissues, either by direct growth into nearby tissue (invasion) or by spread of cells to other sites (metastasis).




Tumors may arise from most of the organs of the genito-urinary tract namely:

*kidneys
*ureters
*bladder
*adrenal glands
*penis
*testis
*prostate




Any cancer, for that matter, warrants the appropriate and immediate attention for the benefit of every patient. The earlier the cancer is dectected, the better is the success rate of cure and survival of the patient.
Urologists recommend annual check-ups especially for those with family histories of cancer.

BETTER BE SAFE!

What are Sexually Transmitted Diseases?

Sexually transmitted diseases (STD) are diseases that are acquired through sexual activity. They include chlamydia, gonorrhea, genital herpes, HIV/AIDS, and syphilis. There are many serious health problems associated with STDs.

Complications of STD infection include:

* pelvic inflammatory disease (PID)
* inflammation of the cervix (cervicitis) in women
* inflammation of the urethra (urethritis)
* inflammation of the prostate (prostatitis) in men
* fertility and reproductive system problems in both sexes.




STDs can be spread by other means than sexual activity, such as contact with body fluids from an infected person, and can be passed from a mother to her newborn baby.

Symptoms of an STD:

* Burning sensation urinating
* Sores, bumps, rashes, or blisters in the genital or anal area
* Abnormal discharge from the vagina or penis
* Itching, pain, or discharge in the anal area
* Redness or swelling in the genital area
* Pain in the pelvic or abdominal area
* Pain, soreness, irritation, or other discomfort during intercourse, or bleeding
after intercourse
* Recurring yeast infections

Remember that many people with STDs may not experience symptoms.

Treatment

Viral STDs, such as genital herpes (HSV), human papillomavirus virus (HPV), and human immunodeficiency virus (HIV), cannot be cured, but symptoms can be managed with medication.

Bacterial STDs, such as gonorrhea and chlamydia, can be cured with antibiotics.

Fungal (e.g., vaginal yeast infection) and parasitic (e.g., trichomoniasis) diseases can be cured with antifungal and antihelminthic agents, respectively.

Early diagnosis and treatment increase the chances for cure.

Lowering Your Risk of STD Infection


* The risk for transmission is dramatically reduced with the use of condoms and other safer sex practices.

* Avoid contact with body fluids and tissues, such as vaginal fluids, semen, and any open sores

If you suspect you have an STD, see your urologist immediately.

SHOOTING BLANKS?

Infertility is the inability to conceive after at least one year of unprotected intercourse. Since most people are able to conceive within this time, physicians recommend that couples unable to do so be assessed for fertility problems (OB-GYN for females; Urologist for males).

In men, hormone disorders, illness, reproductive anatomy trauma and obstruction, and sexual dysfunction can temporarily or permanently affect sperm and prevent conception. Some disorders become more difficult to treat the longer they persist without treatment.

Infertility can result from a condition that is present at birth (congenital) or can develop later (acquired).

Listed below are common causes of infertility:

* Chemotherapy
* Defect or obstruction in the reproductive system (e.g., cryptorchidism, anorchia)
* Disease (e.g., cystic fibrosis, sickle cell anemia, sexually transmitted disease
[STD])
* Hormone dysfunction (caused by disorder in the hypothalamic-pituitary-gonadal
axis)
* Infection (e.g., prostatitis, epididymitis, orchitis)
* Injury (e.g., testicular trauma)
* Medications (e.g., to treat high blood pressure, arthritis)
* Metabolic disorders such as hemochromatosis (affects how the body uses and stores iron)
* Retrograde ejaculation (i.e., condition in which semen flows backwards into the
bladder during ejaculation)
* Systemic disease (e.g., high fever, infection, kidney disease)
* Testicular cancer
* Varicocele

A thorough examination and a review of the man's medical and surgical history are necessary, because chronic disease, pelvic injury, childhood illness, abdominal or reproductive organ surgery, recreational drug use, and medications can affect fertility. Physical examination may detect testicular irregularities (e.g., varicocele, absence of vas deferens, tumor), evidence of hormonal disorders (e.g., underdeveloped reproductive organs, enlarged breast tissue), or evidence of testosterone deficiency.

A semen analysis is done to examine the entire ejaculate, because seminal fluid can affect sperm function and movement. Generally, three semen samples are taken at different times to account for variables such as temperature and error.

Treatment options include the following:

* assisted reproduction
* medical treatment
* surgery

LOW BATT?

Erectile dysfunction (ED) is the inability of a man to achieve or maintain an erection sufficient for satisfactory sexual performance. Most men experience this at some point in their lives, usually by age 40, and are not psychologically affected by it. This results from decrease in the blood flow in the penis thereby causing lesser penile stiffness.

There are many underlying physical and psychological causes of erectile dysfunction. Reduced blood flow to the penis and nerve damage are the most common physical causes.



Listed below are conditions commonly associated with ED:
* Vascular disease
* Diabetes
* Drugs
* Hormone disorders
* Neurologic conditions
* Pelvic trauma, surgery, radiation therapy
* Peyronie's disease
* Venous leak
* Psychological conditions

Whether the cause of impotence is physiological or psychological, both the patient and his partner often experience a range of intense feelings and emotions. Any of these feelings can lead to a sense of hopelessness and lower self-esteem.

Of course, feelings of sexual insecurity can reinforce any performance anxiety a man experiences and create a vicious cycle of repeated failures and increasingly negative feelings.

Treatment options include counseling, behaviour and lifestyle changes, oral medications, penile injections and the placement of penile prostheses.

The goal of treatment:

FOR CHILDREN

Pediatric urology involves the diagnosis and treatment of congenital(inborn) or acquired urological conditions in children (newborns to early adult age). The most common condition is urinary tract infection (UTI).







These are some commonly encountered conditions that warrant a pediatric urologic consult, evaluation and management.



- undescended testis (testis is not in the scrotum)


- vesicoureteral reflux (back up of urine from the bladder to the ureters and/or kidney)


- urinary tract obstruction (UPJ stenosis)





- hypospadias (abnormally located opening of the penis)


- hydrocoele (enlargement of the scrotum caused by a fluid filled sac)


- recurrent UTI especially in males
- bladder control problems such as bedwetting
- phimosis (very tight foreskin of the penis)
- antenatal hydronephrosis (distention of the kidneys of the fetus noted during
prenatal ultrasound of the mother)
- tumors of the urinary tract in children (kidney or bladder tumors most common)
- hernia

The best time to bring the child for consult with a urologist for the above conditions is between the age of 6 mos to 12 mos. The earlier the condition is diagnosed, evaluated, treated and corrected, the better are the treatment success rates. Most pediatric conditions require surgery to correct the problem.

KEYHOLE UROLOGIC SURGERY (LAPAROSCOPY)

Laparoscopy was first performed in 1901 by Kellig to view the abdomen of a dog. A century later, it has gained popularity and widespread use in multiple specialties. Dr Clayman of UCLA-Irvine was the first urologist to perform laparoscopic procedures during the early 90's. Presently, laparoscopy is slowly being included in the urologist's armamentarium.

Laparoscopic urology is a technique in performing major urologic surgery through several tiny (0.5cm to 1.0cm) incisions, instead of the long incisions, that have been traditionally used. Laparoscopy uses a camera that is inserted inside the abdomen through one of the small incisions so that organs can be visualized using a telescope, and manipulated with long thin instruments likewise inserted into the abdomen through small incisions.

Although in essence this technique employs keyhole surgery, the view obtained is much better than looking through a keyhole. Modern camera equipment produces a wide, bright, clear, magnified view of the operation.

Additionally, though using only small incisions, laparoscopic surgery requires general anesthesia like open surgery.

Many documented advantages have been demonstrated compared with the traditional open surgery.

* Because of the small wound size, this technique produces much less pain thus requiring less pain medications
* Less blood loss
* Shorter hospital stay
* Favorable cosmetic result with smaller scars
* Recovery time greatly reduced resulting to earlier return to work and normal daily activities

Whatever is the goal of open surgery can also be achieved using laparoscopic surgery

The are several urologic procedures being done laparoscopically namely:

* Laparoscopic lymph node dissection
* Laparoscopic adrenalectomy
* Laparoscopic cyst unroofing/decortication
* Laparoscopic nephrectomy
* Laparoscopic partial nephrectomy
* Laparoscopic nephroureterectomy
* Laparoscopic radical nephrectomy
* Laparoscopic donor nephrectomy
* Laparoscopic pyeloplasty
* Laparoscopic radical prostatectomy


The estimated complication rate of laparoscopic urologic surgery is less than 5%. The most common risks include bleeding, infection, and injury to adjacent organs such as liver, bowel, spleen, pancreas and vascular structures. These complications do also happen with open surgery.

Conversion to open surgery after initial attempts of laparoscopy are sometimes necessary to safely complete the procedure but is never considered a failure of surgery.

Although laparoscopic surgery is easier on the patient than open surgery, it is technically more difficult to perform than that of equivalent traditional open surgery that it sometimes takes longer time to perform.


In the Philippines, the National Kidney and Transplant Institute is the pioneer institution where this procedure is commonly performed and has the largest experience with this technique.

Laparoscopic milestones in the National Kidney and Transplant Institute

2001 first laparoscopic pelvic lymph node dissection.
first laparoscopic hand-assisted nephrectomy

2002 first laparoscopic adrenalectomy
first full laparoscopic nephrectomy

2003 first full laparoscopic radical nephrectomy

2004 first laparoscopic donor nephrectomy
first laparoscopic radical prostatectomy

2005 first laparoscopic orchiectomy for undescended abdominal testis
2007 first laparoscopic partial nephrectomy

Laparoscopic procedures for urology is gaining popularity in our country. IT IS NOTEWORTHY TO KNOW THAT THE EXPERTISE IN LAPAROSCOPIC UROLOGY IS ALREADY AVAILABLE IN DAVAO CITY AND SOME INSTITUTIONS HERE IN THE CITY ALREADY HAVE LAPAROSCOPIC INSTRUMENTS.


LAPAROSCOPIC DONOR NEPHRECTOMY (NKTI)

FOR MEN AGED 40 YEARS OLD AND ABOVE

Prostate gland and urinary problems

The prostate gland is a male reproductive organ. Many men experience urinary changes as they age, which may be caused by inflammation or enlargement of the prostate gland. An enlarged prostate gland, however, does not always cause urinary problems. Troublesome urinary symptoms are rarely symptoms of prostate cancer.

The prostate gland is about the size of a walnut and is found at the base of the bladder. A thin tube that allows the passage of urine out of the penis (urethra) runs through the prostate gland. Fluid produced by this gland helps to nourish and support sperm, which come from the seminal vesicles via the ejaculatory ducts into the urethra.




How the prostate gland develops

The prostate undergoes two main growth spurts. The first is triggered by sex hormones made by the testicles during puberty. This prompts the gland to reach an average weight of 20g. The second growth spurt begins when men are in their 40s.

Urinary changes are common as men age

Many men experience urinary symptoms as they age, which may be caused by inflammation of the prostate gland (prostatitis). In the older male, symptoms may be the result of a blockage in the tubes due to a benign (non-cancerous) enlargement of the prostate gland (benign prostatic hyperplasia). The most common symptom is difficulty emptying your bladder.

Urinary symptoms may become sufficiently difficult that they require treatment.

Common urinary symptoms associated with aging

Not all urinary symptoms are due to changes to the prostate. Also, some men have enlarged prostates and yet experience few, if any, symptoms.

Urinary symptoms commonly experienced include:

* The need to urinate frequently during the night
* Urinating more often during the day
* Urinary urgency – the urge to urinate can be so strong and sudden that the toilet may not be reached in time
* The urine stream is slow to start
* Urine dribbling some time after finishing urination
* A sensation that the bladder isn’t fully emptied after urination
* Lack of force to the urine flow, which makes directing the stream difficult
* The sensation of needing to go again soon after urinating.




Although these symptoms often do not need treatment, you should see your doctor if they are particularly difficult as they can be successfully treated.

Symptoms that should be followed up

See your urologist if you have the following symptoms:

* Inability to urinate
* Painful urination
* Any blood in the urine at all
* Any discharge from the penis
* Continuous or severe urinary incontinence (you can’t hold your urine).

Inflammation of the prostate

Bacteria sometimes cause prostatitis (inflammation of the prostate). More commonly, however, the underlying cause is uncertain. If the following symptoms are present, you should consult your urologist promptly:

* Fever
* Low back pain
* Pain in the groin
* Urgent and frequent urination.

Antibiotic treatment is essential for acute bacterial prostatitis. Admission to hospital is often necessary and, as with chronic prostatitis, specific antibacterial drugs are required for a long time.

Enlargement of the prostate
Benign prostatic hyperplasia (BPH) causes enlargement of the prostate, which may cause troublesome symptoms. BPH is more common as men get older.

The prostate gland goes around the urethra, so men may have problems urinating if the enlarged gland restricts the flow of urine. If the flow stops completely, a catheter is required to empty the bladder. It is rare for this form of acute urinary retention to cause kidney damage.



An enlarged prostate doesn’t always cause urinary problems. Studies indicate that the size of a man’s prostate gland has little influence on the type or severity of his urination problems. BPH is just one possible cause of urinary symptoms.


Diagnosis
If you are troubled by urination problems, you should see a urologist – no matter what your age. If your doctor agrees that your symptoms need further evaluation and treatment, you may need to undergo a few tests. These may include:

* Physical examination – including digital rectal examination (DRE) to check the size and shape of the prostate gland.
* A urine check – to ensure the prostate is not infected.
* An ultrasound examination – to assess if the bladder is emptying completely and to examine the appearances of your kidneys.


Digital Rectal Exam(DRE)

Treatment

If your urinary problems are caused by infection or enlargement of the prostate gland, treatment options include:

* For prostatitis – a prolonged course of antibacterial drugs. Because infection is difficult to eradicate, they will need to be taken for many weeks.

* For obstruction caused by an enlarged prostate

a) Medical treatment: medications to relax the muscles of the urethra to facilitate passage of urine

b) Surgical treatment: Transurethral incision of the prostate (TUIP), Transurethral resection of the prostate (TURP), open prostatectomy (for very large prostate glands)


TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)


OPEN PROSTATECTOMY

Things to remember

* The prostate gland is a male reproductive organ that contributes fluids to nourish sperm cells in the ejaculate.
* Many men experience urinary changes as they age. In many cases, these changes do not need specific treatment.
* When urinary changes cause problems, they can be treated successfully by lifestyle changes, medication, surgery or both.
* For problems such as blood in the urine, pain on urination, inability to urinate or uncontrollable urine flow, you should see your urologist promptly.

STONES, STONES

Kidney stones are hard objects, made up of millions of tiny crystals. Most kidney stones form on the interior surface of the kidney, where urine leaves the kidney tissue and enters the urinary collecting system. Kidney stones can be small, like a tiny pebble or grain of sand, but often are much larger.

The job of the kidneys is to maintain the body's balance of water, minerals and salts. Urine is the product of this filtering process. Under certain conditions, substances normally dissolved in urine such as calcium, oxalate, and phosphate, become too concentrated and can separate out as crystals. A kidney stone develops when these crystals attach to one another, accumulating into a small mass, or stone.






Kidney stones come in a variety of mineral types.

1. Calcium Stones: Most kidney stones are composed of calcium and oxalate. Many people who form calcium containing stones have too much calcium in their urine, a condition known as hypercalciuria. There are several reasons why hypercalciuria may occur. Some people absorb too much calcium from their intestines. Others absorb too much calcium from their bones. Still others have kidneys which do not correctly regulate the amount of calcium they release into the urine. There are some people who form calcium oxalate stones as a result of too much oxalate in the urine, a condition known as hyperoxaluria. In some cases, too much oxalate in the urine is a result of inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, or other times it may be a consequence of prior intestinal surgery. Calcium phosphate stones, another kind of calcium stone, are much less common than calcium oxalate stones. For some people, calcium phosphate stones form as a result of a medical condition known as renal tubular acidosis.

2. Struvite Stones: Some patients form stones that are composed of a mixture of magnesium, ammonium, phosphate, and calcium carbonate, which is known as struvite. These stones form as a result of infection with certain types of bacteria that can produce ammonia. Ammonia acts to raise the pH of urine which makes it alkaline and promotes the formation of struvite.

3. Uric Acid Stones: Uric acid is produced when the body metabolizes protein. When the pH of urine drops below 5.5, urine becomes saturated with uric acid crystals, a condition known as hyperuricosuria. When there is too much uric acid in the urine, stones can form. Uric acid stones are more common in people who consume large amounts of protein, such as that found in red meat or poultry. People with gout can also form uric acid stones.

4. Cystine Stones: Cystine stones are rare, and they form only in persons with an inherited metabolic disorder that causes high levels of cystine in the urine, a condition known as cystinuria.

HOW IS A KIDNEY STONE DIAGNOSED?

Most people are diagnosed with kidney stones after the thunderclap onset of excruciating and unforgettable pain. This severe pain occurs when the kidney stone breaks loose from the place that it formed, the renal papilla, and falls into the urinary collecting system. When this happens, the stone can block the drainage of urine from the kidney, a condition known as renal colic. The pain may begin in the lower back, and may move to the side or the groin. Other symptoms may include blood in the urine (hematuria), frequent or persistent urinary tract infections, urinary urgency or frequency, and nausea or vomiting.

When your urologist evaluates you for a kidney stone, the first step will be a complete history and physical examination. Important information regarding current symptoms, previous stone events, medical illnesses and conditions, medications, dietary history, and family history will all be collected. A physical examination will be performed, to evaluate for signs of a kidney stone, such as pain in the flank, lower abdomen, or groin.

Your urologist will perform a urinalysis, to look for blood or infection in the urine. A blood sample will also be collected so that kidney function and blood counts can be measured.

Even though all of these tests are necessary, a kidney stone can only be definitively diagnosed by a radiologic evaluation. In some cases, an ultrasound or a simple x-ray, called a KUB, will be adequate to detect a stone. If your urologist requires more information, an intravenous pyelogram (IVP) or a CT stonogram may be necessary.

So You Have A Kidney Stone - What Now

This depends on symptoms, where the stone is in the urinary tract and how big it is.

The type of treatment depends on size, composition and position of the stone. It also depends on your Urologists expertise.

For Stones In The Kidney

The types of treatment include:

a. Dissolution - that is dissolving with medication - only applies to uric acid stones.

b. 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 sand-like particles and are easily passed through the urinary tract in the urine.

In most cases, ESWL may be done on an outpatient basis. Recovery time is short, and most people can resume normal activities in a few days.

Complications may occur with ESWL. Most patients have blood in their urine for a few days after treatment. Minor discomfort in the back or abdomen from the shock waves are also common. To reduce the risk of complications, doctors usually tell patients to avoid taking aspirin and other drugs that affect blood clotting for several weeks before treatment.

Another complication may occur if the shattered stone particles cause discomfort as they pass through the urinary tract.

In some cases, the doctor will insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Sometimes the stone is not completely shattered with one treatment, and additional treatments may be needed. SWL is not ideal for stones more than 3 cms.




This is a segment on an episode in QTV11's RX Men last Sept 2007

c. Percutaneous nephrostolithotomy (PCNL) - In this procedure, the surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. Using an instrument called a nephroscope, the surgeon locates and removes the stone. For large stones, some type of energy probe (kinetic or laser) may be needed to break the stone into small pieces. Generally, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process.
One advantage of percutaneous nephrolithotomy over SWL is that the surgeon removes the stone fragments instead of relying on their natural passage from the kidney.

Illustration of percutaneous nephrolithotomy





d. Open Stone Surgery

This option is still very reliable in our setting.An incision is made on your flank to gain access to the location where the stone is found. This procedure is indicated for large stone burden where ESWL is not a good treatment option, if percutaneous nephrostolithotomy instruments are not available or if an anatomic defect is present leading to stone formation.

Below is a video of a pelvolithotomy (open stone surgery) which I performed



Sometimes kidney stones do not cause any symptoms at all. Such painless stones can be discovered when your doctor is looking for other things on x-rays. Sometimes, although a stone does not cause any pain, it can cause other problems such as recurring urinary tract infections or blood in the urine. It is important not to take these symptoms for granted as it can later lead to damage to your kidneys and eventually kidney failure.

(References: Urology at Hopkins and Urology Sydney)

DEFINITION OF UROLOGY

Urology is the branch of medicine that takes care of the medical and surgical diseases of the adrenals, kidneys and urinary tract, which include the ureters, bladder and urethra, and the male reproductive system and genitalia (testes, epididymis, vas deferens, seminal vesicles, prostate and penis).. In men, the urinary system overlaps with the reproductive system, and in women the urinary tract opens into the vulva. In both sexes, the urinary and reproductive tracts are close together, and disorders of one often affect the other.

Urology combines management of medical (i.e., non-surgical) problems such as urinary infections, and surgical problems such as the correction of congenital abnormalities and the surgical management of stones and cancers. Such abnormalities within the genital region are called genitourinary disorders.

Urology was mentioned in the original Greek version of the Hippocratic Oath, wherein specific prohibitions are contained for physicans against cutting "persons labouring under the stone" and to leave it to those who are practioners of this work. Urologic diseases has been described as far back as the ancient Egyptians who did routine suprapubic cystostomies on patients with urinary retention for bladder stones or enlarged prostates.

Historically, the subject which clearly established the specialty of urology as being distinct from general surgery was the treatment of urinary tract obstruction. This treatment ranges from the correction of obstructing posterior urethral valves or ureteropelvic junction obstruction in the infant to the correction of bladder outlet obstruction from benign prostatic hyperplasia in the older male.
Although urology is classified as a surgical specialty, a knowledge of internal medicine, pediatrics, gynecology, and other specialties is required by the urologist because of the wide variety of clinical problems encountered. In recognition of the wide scope of urology, the American Urological Association has identified seven branches:
• Pediatric Urology
• Urologic Oncology (cancer)
• Renal Transplantation
• Male Infertility
• Calculi (urinary tract stones)
• Female Urology (urinary incontinence and pelvic outlet relaxation disorders)
• Neurourology (voiding disorders, urodynamic evaluation of patients and
erectile dysfunction or impotence)

A urologist is a “physician and surgeon” who is trained in this branch of surgery and is the expert in diagnosis and treatment of disorders of the adrenal glands, kidneys, ureters, and urinary bladder in MEN AND WOMEN OF ANY AGE as well as the male reproductive and genital tract.

COMMON PROBLEMS HANDLED BY THE UROLOGIST
KIDNEY, URETERS, BLADDER - stones, tumors, traumatic injury
PROSTATE – Benign prostate enlargement, infection, cancer
ADRENAL - Adrenal adenoma, pheochromocytoma
GENITALIA/TESTIS – Tumors, traumatic injury, hydrocoele, orchitis
MALE INFERTILITY – low sperm count, varicocoele
MALE SEXUAL DYSFUNCTION – Erectile dysfunction, Premature ejaculation
INFECTIONS - Sexually transmitted diseases, Urinary tract infection
PEDIATRIC PROBLEMS – undescended testis, hypospadias, hydrocoele, phimosis, vesicoureteral reflux, intersex, ureteropelvic junction obstruction

UROLOGY TRAINING AT NATIONAL KIDNEY AND TRANSPLANT INSTITUTE

How time flies....It seems like only yesterday. On December 8, 2003, I received a call from Paz , the secretary of NKTI Urology Dept telling me to go to NKTI and start my pre-fellowship. I took care of everything that I had to before I left Davao. When I started on Dec 15, 2003, I was awed by everything that was in the institution. For a government hospital, it was really surprising. The whole hospital had centralized airconditioning and was so clean. The instruments in the operating room were complete, ask for it and they have it and everything was so well organized. The facilities were A1. The requests for laboratories, xrays and other ancillary procedures are done thru a click of a mouse! Each ward has a computer where the requests are sent and the results can be viewed and printed in the ward after 1 hour!Fantastic! Its something that even the expensive hospitals here in Davao City don't have.

I was used to the laid back life here in Davao and I asked myself, am I ready for the fast paced life in Manila? I know that the level of training there is really really different from what we have in other places. When I was in my first year, I had to be on my toes at all times, making follow ups on labs, xrays and OR schedules, making sure that every hole has been covered. With super strict seniors, we couldn't relax. As I climbed up the ladder annually, I became more strict each day that passes by because I didnt want mistakes that we did to be committed by our juniors. I became better each day at what I did, theoretically and technically. It was really tiring, physically and mentally, but it was all worth it. My day wouldnt be complete if I didnt do at least one surgery. I consider myself very lucky to be trained at NKTI and be mentored by a consultant staff considered to be the who's who in Philippine urology.

Well, training wise, we had more than enough teaching material. The Urology office library had a wide array of textbooks and journals as well as broadband internet access. Research work is one of the requirements in any training program. Material for research was more than adequate and we had the support and supervision to complete our researches.(Thanks to Dr Joben Abraham)

Our outpatient clinic is one of the busiest in the hospital since we see close to 80 patients per clinic day with a variety of urologic problems to challenge our neurons and decision making abilities.

Honing my surgical skills was not a problem since we had many cases to do. Not only was I trained in open surgery but I was also trained in endourology and minimally invasive urology as well as ESWL. (Thanks to Drs JB Mendoza & Joey Morales)

The creation of the prostate health clinic last 2005 allowed us to focus on the group of patients with prostate problems and helped us greatly in the diagnosis, medical and surgical treatment of such problems. We were also trained to perform transrectal ultrasound guided prostate biopsy since the department has an own ultrasound machine in the operating room. We also have minimally invasive procedure for treament of prostate cancer, the HIFU (high intensity focused ultrasound), the first and only in Asia. (Thanks to Drs Dave Abraham & Genlinus Yusi)

I was also lucky to have been able to work with and be supervised by four pediatric urologists. Having a separate pediatric urology clinic helped us in handling genitourinary disorders in the pediatric age group. (Thanks to Drs Dante Dator, Mon Torres, Mike Gaston & Niko Magsanoc)

We also boast of urologic oncologists who provided us the knowlege in genitourinary cancers as well as tips and tricks in doing urologic cancer surgery. (Thanks to Drs Abe Prodigalidad, Rey dela Cruz & Jimmy Songco)

One advantage of our program is that NKTI is a transplant center so we have an extensive exposure and hands-on experience in performing kidney harvest for transplantation. (Thanks to Drs Genaro Yusi, Ed Rivera, Sonny Patron, Awe Lenon, Luis Florencio & Genlinus Yusi)

To highlight my training, our batch(NKTI Urology batch 2007) was the first among the training institutions to have laparoscopy integrated in the training curriculum. We held post graduate courses each year starting 2004. We also have an in-house animal workshop to practice our dexterity in performing the procedures. Then we started as assistant surgeons for laparoscopic procedures then eventually being the surgeon. It is one of the advancements in our training. I, together with my 2 batchmates are trained and qualified to perform laparoscopic procedures. (Thanks to Drs JV Prodigalidad and Jun Gerial)

My stay in NKTI is not only about the training, we all know that it is the best institute when it comes to Urology training. Its also about friendship and camarederie, problems and solutions, and a lot more lessons in life. I knew that my training would end on December 2007 and I had to start private practice on 2008 to carry on all the skills and knowledge that the best institution has imparted on me.

Sadly, I had to leave NKTI when I completed my training...even though I was done with my training, there's always a part of me that belongs to NKTI...

I knew I had to go, but I wanted to look for reasons to stay.

I am so thankful that I had the opportunity to train in NKTI and to work with and be supervised by the best urology consultant staff.

NKTI Website




NKTI Department of Urology Consultant and Fellow Staff 2006 (click on picture to enlarge)


NKTI Urology Fellows 2007


Operating Room Action - That's me performing my favorite surgery, Donor Nephrectomy (Kidney harvest for transplant)