OF D'S AND F'S

Many people wonder what these acronyms mean when they visit the doctors' clinic...aside from MD there are D's and F's i.e. DPBU, DPBS, DPOGS, DPCP, DPPS, DPBA and FPUA, FPCS, FPOGS, FPCP, FPPS,  etc...

Now, what does the D mean? It stands for DIPLOMATE (DPBU- Diplomate, Philippine Board of Urology).  It is defined as an individual who has earned a diploma or certificate, especially a physician who has been certified by a specialty board (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.).  A person with a degree of higher education, a diplomate 
Graduate education A physician who is board-certified in a particular specialty and holds a diploma from a specialty board. (McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.).

Then we come to the F.  It stands for FELLOW (FPUA - Fellow, Philippine Urological Association).   
1) A physician who has attained specified credentials required for admittance to a professional organization.
2) A physician who enters a training program in a medical specialty after completing residency, usually in a hospital or academic setting.
(The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company).

Here in the Philippines, each medical specialty has an accreditation body that is in charge of evaluating the training institutions as well as its trainees and graduates.  Each training institution is evaluated based on the number of cases, beds, trainees (residents/fellows), equipment and instruments, educational material etc.  For the residents, there is an annual evaluating exam also known as the residency in service exam.

To become a DIPLOMATE, one must be a graduate of an accredited training program before qualifying to take the  diplomate exams.  The type of exams as well as the time as to the eligilibility to take the exam varies on the specialty board.  There are specialty boards that give written and oral exams while there are some that give written, oral and practical exams.  After complying with the requirements and passing these exams, one is a certified diplomate and will be inducted by the specialty board.

To become a FELLOW, one must be a diplomate and then has to apply to the organization where the specialty belongs.  Each specialty organization has their criteria for acceptance and the applicant has to submit the necessary credentials.  Once the criteria is met and credentials have been reviewed and accepted, the applicant will be notified and will be inducted. 

Oath taking led by Dr Nelson Patron, Chairman, Philippine Board of Urology at EDSA, Shangrila during the Philippine Urological Association Annual Convention, Nov 26, 2009

Members of the PBU (L-R) - Dr Ariel Zerrudo, Dr Jesus Benjamin Mendoza, Dr Eduardo Gatchalian

Oath taking

My diplomate certificate from the Philippine Board of Urology

Research Papers Done

Specialty training is not only full of eight or twenty four hour duties, ward calls, ER calls, operating room procedures, OPD consultations, there is also room for research work.  All training programs whether you are in the medical or surgical specialty, have a required number of research papers to be completed.

 

Above: Presenting my case report on "Bilateral Ureteropelvic Junction Stenosis in the Upper Moieties of a Complete Duplex Collecting System" during the St Lukes Medical Center Urology Week 2005.  This case report was published in the Philippine Journal of Urology Dec 2005.
Below: All smiles as I won 2nd place during this case report contest.

This was taken during 2005 Philippine Urological Association Annual Convention when I presented a poster on my research paper "Complications of Transrectal Ultrasound Biopsy of the Prostate in the National Kidney and Transplant Institute". 

Letter from the Asia Pacific Association of Pediatric Urologists for the 9th Annual Meeting in Shanghai, China held last December 2007.

I had an oral presention on the paper "Endoscopic Correction of Vesicoureteral Reflux Using Dextranomerhyaluronic Acid Copolymer (Deflux) in the Philippines".

My paper published in an international journal, Journal of Pediatric Urology, Feb 2008.

This is the first reported case in local and international literature.

VARICOCELE

Varicocele is a clump of enlarged and engorged veins that develops in the spermatic cord within the scrotal sac. The spermatic cord is made up of veins, arteries, lymphatic vessels, nerves, and vas deferens.

If the valves that regulate bloodflow from these veins are defective (usually from birth), blood does not drain from the testicles efficiently, causing swelling in the veins above and behind the testicles.The pooling of blood in the engorged vessels results in warming of the testis.


A varicocele can develop in one or both testicles, but in about 85% of cases, the left testicle is involved.
A varicocele is found in approximately 15% of  men.  In men evaluated for infertility , varicoceles are found in approximately 40% of patients.

Varicocele affects semen quality because of increased heat to the testicle. The dilated veins allow warm blood from the abdominal cavity to flow around the testicle. This causes overheating of the testicle which then impairs its function. Commonly, a low sperm count, poor movement, and abnormally shaped sperm are found in men with varicoceles. A varicocele surrounding 1 testicle may affect the testicle on the opposite side of the body. A varicocele may also lead to impaired growth of the testicle and thus the testicle on the side of a varicocele may be smaller than the other..

Signs and symptoms

Most men with varicocoeles have no symptoms and they are diagnosed on routine physical examination or during infertility work up.

Signs and symptoms include the following:

• Pain in the testicle
• Feeling of heaviness or discomfort in the testicle(s) 
• Infertility
  
• Shrinkage of the testicle(s)
• Visible enlarged vein or vein that is able to be felt

 Large varicoceles are easily identified on physical examination; they have the classic "bag of worms" appearance surrounding the testis.

Grading of varicocoeles:

• Grade 1-  varicocele that is palpable only during straining (Valsalva maneuver).
• Grade 2 - varicocele in which the lesion is palpable without a Valsalva maneuver.
• Grade 3 - varicocele that is visually detectable

Diagnostics:

Ultrasound is the examination of choice for investigating varicoceles, and it remains the most practical and most accurate noninvasive technique.

Treatment

If the varicocele causes pain or decreased size of the testis (rare) or if the condition is causing infertility (most common), surgery is recommended.

Urologists correct varicoceles by performing a surgical procedure called varicocelectomy.


The Male Infertility Best Practice Policy Committee of the American Urological Association recommends that varicocele treatment should be offered to the male partner of a couple attempting to conceive when all of the following are present

• A varicocele can be felt..
• The couple has documented infertility.
• The female has normal fertility or potentially correctable infertility.
• The male partner has one or more abnormal semen parameters or sperm function test results.

In addition, adult men whose varicocele can be felt and semen analyses show abnormal findings but are not currently attempting to conceive should also be offered varicocele repair.

A varicocele is the most correctable factor in a male with poor semen quality; therefore, varicocele repair should be considered a viable option for individuals and couples with otherwise unexplained infertility because varicocele repair has been shown to improve semen parameters in most men and possibly improve fertility.

VESICOURETERAL REFLUX

What is vesicoureteral reflux? (VUR)

The normal urination process involves bladder contraction and urine flow out of the body through the urethra.

With vesicoureteral reflux (VUR), some urine goes back up into the ureters and possibly up to the kidneys. This process exposes the kidneys to infection.

In children, especially those in the first 6 years of life, urinary infection can cause kidney damage. The injury caused by infection to the kidney may result in scars in the kidney and loss of future growth potential or widespread scarring and loss of the normal kidney tissues. Even a small area of scarring in one kidney may be a cause of high blood pressure later in life. Untreated, severe reflux on both sides can result in kidney failure requiring dialysis or kidney transplantation.

VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with a UTI are found to have VUR.

VUR can lead to infection because urine that remains in the  urinary tract provides a place for bacteria to grow. But sometimes the infection itself is the cause of VUR.

There are undetermined genetic risk factors which may affect the development of VUR. About 34% of patients who have the condition have siblings who are also affected.

Types of VUR:

Primary reflux

The most common cause for primary reflux in children is an abnormality in the section of the ureter that enters the bladder ( intravesical ureter). The intravesical ureter may not be long enough to enable the ureter to sufficiently act as a valve to prevent urine reflux, or the ureter may be inserted abnormally into the bladder.

Other causes of primary reflux include abnormalities in muscle of the bladder, abnormalities in the location of the urethral opening and abnormalities in the shape of the urethral opening. 

Secondary reflux

Secondary reflux is often caused by urinary tract infection which causes inflammation and swelling of the ureter. UTI may cause vesicoureteral reflux or vesicoureteral reflux may promote the growth of bacteria in the urinary tract, causing UTI.

Secondary reflux may also be caused by urinary tract abnormalities like narrowing of the ureter; duplicated ureters; ureterocele) and obstructions from stones or tumors. 



Evaluation

An ultrasound of the kidneys and bladder is done to 1) evaluate hydroneprosis and kidney growth and 2) detect abnormalities that cause reflux.

A renal scan is done to evaluate kidney growth and detect presence of scarring.

A voiding cystourethrogram (VCUG) is performed to determine if an abnormality in the urinary tract is causing reflux. A contrast dye is instilled into the bladder through a catheter and a series of x-rays are taken.

Grading of VUR

Grade I (least severe) to Grade V (most severe):

• Grade I results in urine reflux into the ureter only.
• Grade II results in urine reflux into the ureter and the renal pelvis, without swelling of the top of the ureter (hydronephrosis).
• Grade III results in reflux into the ureter and the renal pelvis, causing mild hydronephrosis.
• Grade IV results in moderate hydronephrosis.
• Grade V results in severe hydronephrosis and twisting of the ureter

Mild-to-moderate degrees of reflux (grades I to III) have a good chance of spontaneous resolution with age in over 80% of children. This typically occurs over the span of few years. Unfortunately, we do not know exactly when the reflux will go away for a particular child.
The chance of spontaneous resolution of high grade reflux (IV to V) is much lower.

Treatment

1) Antibiotic prophylaxis for VUR Gr II-III
2) Endoscopic treatment for VUR Gr I-IV
3) Open surgery  for VUR Gr IV-V


Follow-Up
All patients with a history of reflux will have life long monitoring. Even if the reflux resolves, there is still risk of developing kidney insufficiency, hypertension, and pregnancy-related problems.This usually involves periodic visits to the pediatrician and have the following taken: height and weight, blood pressure, and urine analysis. Kidney function can be evaluated by blood tests (creatinine and BUN) or by creatinine clearance or glomerular filtration rate. Occasional ultrasound tests will ensure that kidney growth is on target for age. Female patients should be carefully monitored during their pregnancy.

UNDESCENDED TESTIS

Undescended testicle, also called cryptorchidism, is a common condition in which one of the testicles is not located within the scrotum. During the eighth month of the mother's pregnancy, the baby's testes migrate from the abdomen, through the groin, and into the pouch that contains the testes (scrotum).

An undescended testicle may be located in the abdominal cavity, in the passageway in the groin (inguinal canal), or in an ectopic location (e.g., superficial pouch in the groin, perineum, upper thigh). This condition is usually present at birth (congenital) and is associated with sterility and an increased risk for testicular cancer if not corrected.

Undescended testicle may occur in approximately 30% of premature males and 3% of full term male infants. In 80% of cases, the undescended testicle migrates into the correct position without intervention during the first year. The condition may involve both testicles in about 10% of cases.

The cause of undescended testicle is not known. If the father or brother ad the conditionm, there is an increased risk. Other risk factors include the following:

* Low birth weight (less than 2500 g)
* Maternal exposure to estrogen during the first trimester
* Multiple birth (e.g., twin, triplet)
* Premature birth (before 37 weeks gestation)
* Small size for gestational age

Diagnosis of this condition is made through physical examination at birth to locate the testis. If one testicle is undescended, the scrotum appears unbalanced. If the undescended testis is felt (palpable) it may not have descended fully, may have descended into a location other than the scrotum (ectopic), or may move in and out of the scrotum through muscle contraction (retractile).

If the testis is non palpable, it may be located within the abdomen or may be absent (occurs in 5% of cases). A congenitally absent testicle may result from an abnormality in testicular blood vessels or testicular torsion in utero.

In humans, the scrotal location of the testicles keeps them cooler than the core body temperature which is important for the development of the testicle as well as for production of normal sperm. Studies have shown that there is an increased risk of infertility in men with a history of undescended testicles. Relocating the testicle into the scrotum may decrease the risk of fertility problems, particularly if done at an early age.

There are other advantages to a location within the scrotum. There is a cosmetic advantage. The scrotal testicle may be at less risk to injury than a testicle outside the scrotum. Finally, and perhaps as important as any other reason, a testicle that has not made it into the scrotum is not accessible to physical examination.

Undescended testicles are at increased risk for cancer. Testicular cancer may not occur until after age 40 years. Testicular carcinoma is highly curable, when detected early, and the best way to do this is monthly self-examination, which can only be done if the testicles are within the scrotum.

It is recommended that treatment of the undescended testicle be done before one year of age. There is evidence that early damage to the germ cells that produce sperm begins at this age.

There are two options for treatment. Injections of a hormone, HCG, several times per week over several weeks can produce descent in some children. However, the success rates have been reported to be as low as 10%. Also, the results of hormone treatment are less successful in children less than two years of age.

The most effective treatment is surgery, which can be performed as an outpatient. When a testis is felt in the groin area we usually explore the area through a small incision. Most undescended testes are associated with a hernia that must be repaired. After this is done, the testis is brought down into the scrotum and anchored in a space created in the scrotum (orchiopexy).

When a testis is not palpable on physical exam, its location must be determined. No x-rays are reliable in this regard. A diagnositic laparoscopy is done. A laparoscope through a small incision below the 'belly button' to look in the abdomen at the time of surgery. In those patients found to have testes very high in the abdomen, additional surgery is required to correct the problem. A number of children will be found to have very small abnormal gonads, removal of the gonad is done. Most of these children probably had torsion or twisting of the testis on its blood supply prior to birth that led to the small testis. When a boy is left with a single functioning testis it is recommended that it be anchored to minimize chances of losing it to torsion later in life.

HYPOSPADIAS

Hypospadias is a birth defect where the boy's urinary opening (urethral meatus) is not in its normal location. It may be located anywhere in the penile shaft, anywhere from tip to base. This condition is often associated with penile twisting, penile curvature/bending (chordee) and a hooded, incomplete foreskin. The degree of hypospadias depends on the location of the penis opening. This is birth defect occurring in one in one hundred to one in two hundred births (1 in 100 to 1 in 200). When we see a boy with hypospadias there is a twenty percent (20%)chance of finding this in another family member such as father or a brother.


The cause of hypospadias is not known. The condition results from abnormal development of the urethra in the embryo and not from anything the parents did or did not do during pregnancy. Hypospadias will occasionally occur in more than one male in a family.

Problems encountered are messy urination because of the direction of the urinary stream, erectile problems and impaired delivery of semen. The most devastating problem encountered is pyschological since those who have severe defects need to sit down when urinating. The ability to stand and urinate is important for boys. When the urethra opens before it reaches the glans a boy may be unable to stand and urinate with a direct stream.The youngster who has to sit down to urinate on a toilet is at a painful social disadvantage. A straight penis is necessary for satisfactory sexual function. Although this may not seem to be an important matter in childhood, this is a crucial concern later in life.

Corrective surgery usually results in a penis that looks normal and functions normally. Surgical correction of hypospadias involves straightening of any chordee and then extension of the urinary tube (urethra) out to the tip of the penis (the glans).Surgery should be performed to correct the condition as soon as is possible - certainly within the first year or two after birth.

Prostate Cancer

Prostate cancer affects the tissues of the prostate gland. It occurs when the cells of the prostate grow uncontrollably. This is the most common malignancy found in men.

Prostate cancer usually grows slowly and initially remains confined to the prostate gland, where it may not cause serious harm. There are some types of prostate cancer grow slowly and may need minimal or no treatment, while there are types which are aggressive and can spread quickly.

If prostate cancer is detected early — when it's still confined to the prostate gland then there is a 90% chance of successful treatment.

Risk factors

* Age. After age 40, the chance of having prostate cancer increases.

* Race or ethnicity. For reasons that aren't well understood, black men have a higher risk of developing prostate cancer.

* Family history. Men with a single first-degree relative—father, brother or son—with a history of prostate cancer are twice as likely to develop the disease, while those with two or more relatives are nearly four times as likely to be diagnosed. The risk is even higher if the affected family members were diagnosed at a young age, with the highest risk seen in men whose family members were diagnosed before age 60.

* Diet. A high-fat diet and obesity may increase the risk of prostate cancer. One theory is that fat increases production of the hormone testosterone, which may promote the development of prostate cancer cells.

* High testosterone levels. Because testosterone naturally stimulates the growth of the prostate gland, men who use testosterone therapy are more likely to develop prostate cancer than are men who have lower levels of testosterone.

Symptoms

Prostate cancer usually doesn't produce any noticeable symptoms in its early stages, so many cases of prostate cancer aren't detected until the cancer has spread beyond the prostate. For most men, prostate cancer is first detected during a routine screening such as a prostate-specific antigen (PSA) test or a digital rectal exam (DRE).

When signs and symptoms do occur, they depend on how advanced the cancer is and how far the cancer has spread.

Less than 5 percent of cases of prostate cancer have urinary problems as the initial symptom. When urinary signs and symptoms do occur, they can include:

* Trouble urinating
* Starting and stopping while urinating
* Decreased force in the stream of urine

Cancer in your prostate or the area around the prostate can cause:

* Blood in your urine
* Blood in your semen

Prostate cancer that has spread to the lymph nodes in your pelvis may cause:

* Swelling in your legs
* Discomfort in the pelvic area

Advanced prostate cancer that has spread to your bones can cause:

* Bone pain that doesn't go away
* Bone fractures
* Compression of the spine



Screening and Diagnosis

The first indication of a problem may come during a routine screening test, such as:

* Digital rectal exam (DRE).
During a DRE, your doctor inserts a gloved, lubricated finger into your rectum to examine your prostate. The texture, shape and size of the gland is evaluated, if abnormalities are noted, there may be a need for more tests.



* Prostate-specific antigen (PSA) test.
PSA, is a substance that's naturally produced by the prostate gland to help liquefy semen. It's normal for a small amount of PSA to enter your bloodstream. However, if a higher than normal level is found, it may be an indication of prostate infection, inflammation, enlargement or cancer. Screening with PSA and DRE can help identify cancer at an earlier stage.

* Transrectal ultrasound guided prostate biopsy.
If other tests raise concerns, a transrectal ultrasound guided prostate biopsy is perfomed to obtain a definitive diagnosis of the prostate pathology.

Who should be screened?

Both the PSA and DRE should be offered annually, beginning at age 40, to men who have at least a 10-year life expectancy. Men at high risk, such as African American men and men with a strong family history of one or more first-degree relatives diagnosed at an early age. However, all men aged 40 and above should speak with their doctors at the the time of their annual physical examinations and develop a prostate health plan.

Treatment options:

Treatment options for prostate cancer vary depending on the grade and stage of the cancer.

For low grade and early stage cancers(localized), surgery is the gold standard of treatment. Radical retropubic prostatectomy offers the highest cure rate for organ confined prostate cancers.

Other options include brachytherapy, radiation therapy, high intensity focused ultrasound (HIFU) and watchful waiting.

For moderately advanced and advanced prostate cancers, hormonal therapy plays an important role. If urinary symptoms are present, a transurethral resection of the prostate combined with the hormonal therapy is recommended.

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)