Urology

Monopolar and Bipolar TURP

What is transurethral resection of the prostate (TURP)?

Transurethral resection of the prostate (TURP) is a procedure that involves the surgical removal of a section of an enlarged prostate gland, using high energy electric current. TURP uses a surgical instrument called a resectoscope (thin metal tube with light source, camera and cutting tool) to excise the prostate tissue. There are two types of TURP: monopolar TURP and bipolar TURP.

What is Monopolar TURP?

Monopolar TURP uses a cutting tool, heated with electric current that flows in one direction through the resectoscope to remove the prostatic tissue. To avoid the travel of stray energy across the body, a fluid (free of electrolytes) is used to irrigate the bladder. However, long exposures with the fluid may damage the neighbouring tissues and cause transurethral resection (TUR) syndrome, a condition characterized by fluid build-up in the blood.

What is Bipolar TURP?

In bipolar TURP, the electrical current is contained within the resectoscope and concentrated at the site of resection of the prostatic tissue. It returns back through the second limb of the resectoscope. This prevents energy from getting dispersed throughout the body. Normal saline (salt water with electrolytes) is used to flush the excised region. This prevents the formation of TUR syndrome. Bipolar TURP is said to cause less bleeding at the site of excision of prostatic tissue.

Kidney Stones

Introduction

The kidneys are two bean-shaped organs that help in the removal of wastes from the body.

As the kidneys filter blood of impurities, minerals and acid salts can accumulate and harden over time. These solid crystalline deposits are called kidney stones, and can form in one or both kidneys. The stones can travel down the urinary tract and block the flow of urine, causing pain and bleeding.

Kidney stone formation is a common urinary system disorder that can form in any individual. However, men, and overweight people are at a higher risk of developing them.

Causes

Kidney stones form when certain salts and minerals in the urine become highly concentrated and build up. This can happen due to

  • Insufficient water intake
  • Treatments for Kidney diseases and cancer
  • Certain medications
  • Family history
  • Intestinal disease such as Crohn’s disease
  • Single functional kidney

Signs and Symptoms

Symptoms of kidney stone formation may not manifest until the stone moves around the kidney or down into the urinary tract. Symptoms may include

  • Severe pain below the ribs, back, sides, lower abdomen, groin and during urination
  • Pain that fluctuates in intensity
  • Frequent urge to urinate
  • Pink, brown or red urine that is cloudy or foul smelling

You should call your doctor if you find it difficult to pass urine, or the pain increases and is accompanied with fever, chills, vomiting and nausea.

Diagnosis

When kidney stones are suspected, your doctor may order blood, urine and imaging tests (X-ray, CT scans) to diagnose the condition. You may also be asked to urinate through a sieve to collect and test the kidney stones that pass in the lab. The results will help your doctor to determine the cause and formulate an appropriate plan for treatment.

Conservative treatment

Treatment depends on the type of stone and its underlying cause. Small kidney stones can be flushed out by drinking plenty of water every day or through medication. Additionally, your doctor may prescribe medication to relieve pain.

Treatment Options

For larger stones, your doctor may suggest certain procedures based on the location and size of the kidney stones.

A non-invasive procedure called extracorporeal shock wave lithotripsy may be recommended to break down large stones. Your surgeon will administer sedatives or local anaesthesia to keep you comfortable. The location of the stones is determined with the help of ultrasound or X-rays. Using a device called a lithotripter, high energy sound waves are passed over the area to be treated from outside the body. The shock waves will vibrate and break the stones down without harming the rest of the body. The stone fragments can now easily pass out through the urine.

Sometimes, your surgeon may use insert a stent or tube before or after the procedure through the bladder or the back into the kidney to hold the urinary tube open, preventing the pieces from blocking the tube.

Another alternative procedure your doctor may suggest is ureteroscopy. This can be used for stones in the urinary tract closer to the bladder. A thin lighted tube called an ureteroscope is inserted through your urinary tract opening, so no incisions are needed for the procedure. Once the stone is located, tiny forceps or a basket shaped instrument at the end of the scope grabs and removes the stones. Larger stones are first broken down with a laser before excision.

Sometimes, a more invasive procedure called percutaneous nephrolithotomy may be performed. Your surgeon will make an incision in your back under general, regional or spinal anaesthesia. A hollow tube with a probe is inserted into the incision. Your surgeon can either remove the stones directly or break them into fragments before excising them.

Prevention

Kidney stones can be prevented by making some lifestyle changes like drinking more water and reducing the intake of excess salt and animal proteins.

Vasectomy

Vasectomy is a minor surgical procedure in which the vas deferens, a thin tube that stores and transports sperm is cut and then tied or sealed so that the sperm can no longer get into the semen. It is a permanent method of birth control in men. It prevents the release of sperm when a man ejaculates.

Vasectomy can be performed by various surgical techniques and they include:

  • Conventional vasectomy: The testicles and scrotum are cleaned with an antiseptic solution .The procedure takes 20 to 30 minutes and may be done by an urologist or a general surgeon. Oral or intravenous (IV) anti-anxiety medications are given to relax and reduce anxiety. A vasectomy is usually done under local anaesthesia to numb the area. Two small punctures or holes are made on the scrotum and a part of vas deferens is removed through the opening. The cut ends of the vas deferens are then tied off with a synthetic thread or a clip. In some cases electro cautery may be used to seal the ends with the heat. The skin is closed with absorbable sutures.
  • No-scalpel technique: It is a technique that uses a small clamp rather than a scalpel to puncture the scrotum. The clamp is poked through the skin of the scrotum and then opened. This technique reduces bleeding, infection and pain and no stitches are needed.
  • Vas clip implant procedure: This technique do not require cutting and suturing the vas deferens, but rather uses a clip known as vas clip to lock and close the vas deferens. This method is not as effective as other methods of sealing off the vas deferens.

Swelling and minor pain may be felt in the scrotum area for several days after vasectomy. Complications that might occur after a vasectomy include bleeding under the skin, infection at the site of incision, sperm leaking from a vas deferens and forming a small lump called sperm granuloma and inflammation of the tubes that carry sperms from the testicles. In rare circumstances, the vas deferens can regrow or recanalize, and if it occurs, it could cause pregnancy.

Instructions to follow after surgery may include:
  • Avoid heavy lifting for a week
  • Apply cold packs to the area
  • Wearing snug underwear to support the scrotum
  • Get plenty of rest

After vasectomy, it usually takes several months for all remaining sperm to ejaculate or reabsorb. Alternative methods of birth control must be used, until a semen sample test shows a zero sperm count.

Vasectomy Reversal

A vasectomy is a surgical procedure performed in men as a means of permanent birth control to prevent reproduction. Vasectomy reversal is a surgical procedure where the ends of the sperm carrying tubes, the vas deferens that were cut and sealed during vasectomy are joined back together to enable reproduction.

Procedure:

Vasectomy reversal is a sophisticated procedure which can be attempted by two different surgical approaches:

  • Vasovasostomy: In this procedure, the cut ends of the vas deferens (the sperm carrying tubes) are reconnected by the surgeon.
  • Vasoepididymostomy: This approach involves the connection of the detached vas deferens to the epididymis (a tube that lies at the back of each testicle and stores sperm).

The surgeon makes the decision whether to employ either of the approaches or a combination based on the fluid sample taken at the start of the procedure.

Vasectomy reversal is generally carried out as a day procedure under general anaesthesia. The surgeon makes a small incision in the skin of the scrotum, the sac that contains the testes. The surrounding structures are retracted to expose the testicle. The vas deferens is carefully cut and inspected for fluid. This fluid will then be examined for the presence of sperm. When the surgeon confirms the presence of sperm with motility, the tubes are reconnected to enable the transit of sperm.

In cases where there is no seminal fluid or fluid is present but has no sperm, a Vasoepididymostomy would be performed in a similar manner except the detached vas deferens would be connected to the epididymis.

Post-operative care:

Following are the post-surgical guidelines to be followed after surgery:

  • Apply ice packs over the scrotum to reduce the post-operative swelling.
  • Your doctor may prescribe medications to help alleviate pain and make you feel comfortable.
  • Wearing an athletic supporter at all times for the first four weeks help support the testicles and reduce swelling and movements.
  • Keep the surgical area clean and dry.
  • Recreational activities such as sports and lifting heavy weights are restricted for a few weeks.
  • Return to work depends on how well you are healing and the type of work or activity level you perform.
  • Sexual activity can be resumed after about six weeks following surgery.

Risks and complications:

The potential risks and complications of vasectomy reversal include:

  • Infection
  • Excessive blood loss
  • Chronic pain
  • Nerve injury
  • Hydrocele, an abnormal collection of fluid in the scrotum

Prostate Biopsy

Introduction

The prostate is a small, walnut-shaped gland that is only present in men. It is involved in providing nutrition to sperm and assisting in their transport.

A prostate biopsy involves the removal of small samples of suspicious tissues from the prostate.

Prostate biopsy is recommended when the results of initial tests, such as prostate-specific antigen (PSA) blood test or digital rectal exam (DRE), raise concerns of possible cancer.

The biopsy procedure is performed by an urologist. During the procedure a fine needle is used to collect tissue samples from the prostate gland.

After the tissue samples are obtained, they are examined under a microscope for cell abnormalities which may denote prostate cancer. Biopsy also helps in evaluating the stage and type of cancer to assist the doctor in formulating the most appropriate treatment option.

Indications for prostate biopsy

As prostate biopsy is employed for early detection of prostate cancer, it is recommended under the following circumstances:

  • The prostate-specific antigen (PSA) blood levels are higher than normal
  • Abnormal findings are detected during digital rectal exam
  • High prostate-specific antigen (PSA) levels even after a normal biopsy
  • Presence of non-cancerous abnormal cells in previous biopsy

Indications for prostate biopsy

As prostate biopsy is employed for early detection of prostate cancer, it is recommended under the following circumstances:

  • The prostate-specific antigen (PSA) blood levels are higher than normal
  • Abnormal findings are detected during digital rectal exam
  • High prostate-specific antigen (PSA) levels even after a normal biopsy
  • Presence of non-cancerous abnormal cells in previous biopsy

Transrectal prostate biopsy procedure

Transrectal prostate biopsy is the most common procedure employed by urologists. During this procedure the patient is placed on their side with their knees pulled up against the chest. In some cases, patients may be asked to lie on their stomachs.

The area around the anus is cleansed and lubricant is applied to enable smooth insertion of the ultrasound probe into the rectum.

Images are generated with the help of transrectal ultrasonography to assist the urologist in guiding the biopsy needle to the prostate.

Local anaesthesia is given to reduce the discomfort related with prostate biopsy.

After proper positioning of the biopsy device, thin, cylindrical sections of tissue are obtained with a hollow, spring-propelled needle.

Usually about 10 to 12 tissue samples are obtained.

This may cause an unpleasant sensation for a short period of time while the samples are being taken. The procedure is usually completed in 5 to 10 minutes.

Post-operative care

After the procedure, patients are prescribed antibiotics to prevent infection. You may notice small amounts of blood in your urine, stools or semen that should resolve in a few weeks. However, consult your doctor immediately in case of prolonged, heavy bleeding, exaggeration of pain, swelling or difficulty urinating.

Risks and complications

Risks factors associated with a prostate biopsy include infections, bleeding and difficulty urinating.

Some patients may develop a urinary tract or prostate infection which can be managed with antibiotics.

Bleeding at the biopsy site is common so patients should abstain from blood-thinning medications for a specified period as advised by the doctor.

Following a prostate biopsy a few patients may notice blood in the semen. This may continue for 4-6 weeks and is not a matter of concern.

In some cases, the patient may have difficulty in passing urine. In such cases a temporary urinary catheter can be inserted.

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