How to Prepare for Whipple's Surgery?

1. Written informed consent

Carcinoma head of the pancreas is a curable cancer if if identified early. The curative surgical procedure is Whipple's procedure also known as pancreaticoduodenectomy. Whipple's procedure is major operation. Your doctor will explain you the condition and the options you have. He will also tell you the risks of the procedure. Then he will take an informed written consent. You should be fit enough to undergo this procedure, because of the cormorbidities associated with the procedure. Therefore, your doctor will ran you through a series of investigations to assess your fitness. 

2. Investigations

 Carcinoma of the pancreas is associated with high level of morbidity. If you are diagnosed to carcinoma of head of the pancreas, you must have suffered months of severe loss of appetite and loss of weight. Severe loss of appetite and loss of wight makes you nutritionally deprived. Therefore, you must be having several deficiencies.

• PT/INR

Vitamin K deficiency is one important nutritional deficiency you can get is you have carcinoma head of pancreas. If you are deprived of this particular vitamin, your blood's ability to clot and prevent bleeding will be impaired. Therefore, your will assess your vitamin k levels by measuring the ability of your blood to coagulate. This is done by measuring the prothrombin time and the international normalize ratio shortly known as PT/INR. If this is high, your coagulation status will be corrected by giving intravenous Vitamin K. Usually 10 mg of vitamin K is given 12 hourly for 3 days. If not you wll be transfused with fresh frozen plasma.

• Serum total protein and albumin levels

Protein and albumin can also be deficient in your body. Hypoalbuminemia is associated with many post-operative complications. Protein deficiency can delay wound healing and thereby increase the hospital stay. When you are deficient of protein, you are a high risk of developing infections, anastomotic leakage, burst abdomen, incisional hernia and intra-abdominal sepsis. Therefore, it is important to measure the serum protein levels and correct them if there is any deficiency. Doing this by increasing oral intake can be a challenge both due to severe loss of appetite and due to malabsorption.

• Full blood count

Usually people who get carcinoma of the pancreas are elderly people. They usually have other cormorbid conditions. Therefore, routine investigations are done to detect those diseases. From the full blood count report your doctor will look at your hemoglobin levels, white cell count, platelet count and the hematocrit. 

• Renal Function Tests

Blood urea, serum electrolyte levels and serum creatinine levels are measured.

3. Routine pre-operative preparations

• Good hydration 

Your doctor will keep you adequately hydrated. It is important to keep your body hydrated because it can prevent post-operative hepatorenal syndrome. Hepatorenal syndrome is renal desfunction occurring along with hepatic disease. 

• Prophylactic antibiotics 
• Six hour fasting
• Booking a intensive care unit bed

Whipple's procedure is a major surgery. You might require intensive care after the procedure. Therefore, your doctor will book a bed in the intensive care unit prior to the surgery. 

Once all above requirements are full filled, you will be sent to the theater. At the theater, the surgeons, anaesthetists and other theater staff will take care of you. All you have to do is try to keep calm.

Why Open Surgery Should not be done for Bladder Tumors?

Bladder tumors are very common. Most of them can be cured easily if identified early. Usually the superficial tumors of the bladder are treated with transurethral resection. They are not resected opening the bladder trans-abdominally. It is because there is a very high risk of tumor deposition along the tract if surgery is done trans-abdomonally.

Can You Get a Fistula Years After Radiotherapy for Cervical Cancer

Cervical cancer is one of the commonest gynecological malignancies all over the world. It can be cured if identified early. Most of the cervical cancers are squamous carcinomas. Squamous carcinomas are highly sensitive to radiotherapy. Therefore, radiotherapy for cervical carcinoma plays a major role in treating cervical cancers. As with any other treatment modality, radiotherapy also has its own set of complication. Fistula formation is one such complication.

A fistula can develop between the bladder and the perineal skin. This occurs as a result of avascular necrosis of the tissues surrounding the bladder. Unfortunately, the fistulas can occur several years after the radiotherapy. The cancer might have disappeared completely by then.  Sometimes ureterovaginal fistula (Between the ureter and the vagina) can coexist with viscicovaginal fistula (between the bladder and the vagina). Therefore, several investigations are done to differentiate one from another. Three swab test is one such investigation.

The three swab test is done by inserting a swab into the vagina and injecting a die through the urethra. The swab will stain with the die, if there is a viscicovaginal fistula. An intravenous urogram (IVU) should be performed to exclude a coexisting ureterovaginal fistula. 

What is Variegated Appearance in Renal Cell Carcinoma

Renal cell carcinomas often affect the upper pole of the kidney. They are usually large, well encapsulated tumours. These tumours are filled with large ammount of cholesterol, which gives them a golden appearance. These large tumours tend to have foci of hemorrhage and necrosis, which gives rise to characteristic Variegated Appearance.

Why Even a Single Episode of Hematuria Needs Investigations?

Hematuria can occur due to various reasons. Out of these reasons urinary tract tumors palys a leading role. Unlike other causes of hematuria, tumors of urinary tract are detrimental unless identified and treated as soon as possible.

Renal cell carcinoma is one such tumor. Renal cell carcinoma is characterized by intermittent episodes of hematuria. Some people can neglect a single episode of hematuria because it can subside without any treatment, but this should not happen. If you ever develop hematuria, you should seek immediate medical help. If not, it will be too late once the tumor has spread throughout the body.

How to Find Out the Cause for Red Colour Urine?

Red coloured urine can occur due to various reasons. Some of the causes of red coloured urine, for example blood in urine, can be very serious. Therefore, it is very important that you seek medical help, if you develop red coloured urine even once.

Red coloured urine does not always mean hematuria (blood in urine). haematuria, haemoglobinuria, myoglobinuria, some foods and some drugs can give rise to red coloured urine. The exact colour of the urine can be helpful to differentiate one from the other. When you say red coloured urine, it can vary from bright red to dark red colour. Dark red or coca cola colour urine indicates myoglobinuria which results from breakdown of muscles. Some drugs can also give a red colour to the urine. Some of these drugs are ethambutol, rifampicin and metronidasole. Some dietary ingredients can also give a red colour to the urine. These instances of red coloured urine are called pseudohaematuria.

The other way to find out the cause of red coloured urine is to know which part of the urine stream do you see the red coloured. Some people have red coloured urine only at the beginning of the stream and some have gross red coloured urine throughout the urine stream and some can complain of red coloured urine at the end of the urine flow.

Hematuria at the beginning of the urine flow is due to urethral strictures or urethral carcinoma. Terminal hematuria is due to a pathology in the bladder neck or the trigone. Even hematuria is often due to a renal pathology..

The commonest causes of hematuria are malignancy, stones and infections. Apart from these three most common causes there are other less common causes of hematuria such as glomerulonephritis, tuberculosis, poly cystic kidney disease, bleeding disorders, some drugs (warfarin, Heparin, Aspirin), benign prostatic hyperplasia and radiation cystitis.

As described above, we can find out the cause of red coloured urine only by describing the nature of it without the help of any investigations. We can always perform investigations to confirm the diagnosis.

What is Von Lindau Hipple Syndrome

Von Hipple Lindau Syndrome is a syndrome associated with renal cell carcinoma. It is characterised by formation of tumors and cysts throughout the body. These tumors and cysts are usually identified during the adulthood. The incidence of this syndrome is 1 in 36 000 people.

The tumors associated with Von Hipple Lindau Syndrome can be either malignant or non-malignant. These tumors can occur in various organs in the body. This syndrome is characterised by having a type of tumor called haemangioblastoma. It is a benign tumour, but can give rise threatening complications.They can occur in the retina, brain and spinal cord and cause serious neurological deficiencies.

The syndrome can give rise to tumours in the kidneys called clear cell renal cell carcinoma. It can also produce adrenal gland tumours callled pheochromocttoma. Pheochromacytoma are benign, but they can produce life threatening coomplications such as very high blood pressure. The syndrome can also present with pancreatic neuroendocrine tumours. Endolymphatic sac tunours are also seen in people with this sndrome.

What is Urine Cytology? How can it Detect Bladder Cancer?

There are several investigations that can confirm bladder carcinoma. urine cytology stays at the top of the list. It is a cery sensitive test to detect carcinoma insitu and high grade transitional cell carcinoma, but it is not sensitive for low grade transitional cell carcinoma.

It is performed in clean catch urine. You should first clean the external genitalia with soap (not with an aniseptic solution). Then you should start pass urine. About 80-100 ml of urine should be collected fron the middle of the urine stream (midstream urine). Then the sample is sent to the laboratory. If there is any delay in transporting the urine sample to the laboratory, it should be stored in a refrigerator. 

The malignant cells can be identified from this urine sample. This test is not recommended for screening purposes, but if it becomes positive , it is a strong marker of bladder carcinoma.

When to Suspect Bladder Cancer?

Bladder cancer is one of the commonest genitourinary tract malignancies. It can be treated and sometimes be cured, if you identify it early. The symptoms of bladder cancer can sometimes be very non specific. Therefore, there should be a high degree of clinical suspicion to identify this disease condition. So, what are the features of bladder cancer?

The most common and highly suspicious clinical presentation of bladder cancer is hematuria. Even a single episode of hematuria is highly indicative of bladder cancer. The other clinical presentations of bladder cancer include,

• Storage symptoms - Storage symptoms include, frequency, urgency, urge incontinence, nocturia and nocturnal enuresis. These symptoms are very non specific and can be the result of other benign conditions of the urinary tract, such as benign prostatic hyperplasia, but urologist always suspect bladder cancer because it is very common and can be cured completely if identified early.
• Dysuria without evidence of infection - Some people with bladder cancer can present with dysuria without evidence of any infection. Evidence of infection include fever with chills and rigors. They complain of pain or burning sensation when passing urine. 
• Recurrent urinary tract infections is another feature of bladder cancer. 
• Microscopic hematuria - Many people with bladder cancer pass red cells with their urine, but the number of red cells in the urine is not enough to give red colour to the urine to be seen in naked eye. These people are sed to have microscopic hematuria. These people are usually detected when a urine full report is performed when they present with any other urinary tract symptom. 
• Pathological fracture - Some people can stay un-noticed for years without developing any symptoms. These people can have advanced bladder carcinoma. The cancer may have spread to distal organs. Bones are a very common site of bladder cancer metastasis. Such people can first present with pathological fractures. The radiographs will show a metastatic lesion and a bladder tumor can be found when looked for a primary site.  
• Obstructive uropathy - Obstructive uropathy is the outcome of obstruction of the urinary tract. One of both ureters can be obstructed due to the tumor. As a result the hydronephroreters develops and the post-renal renal failure can occur. The patient can present with features of renal failure such as generalised body swelling, especially peri-orbital swelling in the morning. 
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Are You at Higher Risk of Developing Bladder Cancer?

There are risk factors for most of the diseases in this world. Similarly, bladder cancer also has a list of its own risk factors. They are,

• Cigarette smoking - 25 -50 %
• Industrial toxins 

Bladder cancer has a very good relationship with industrial toxins such as rubber, leather and textile. Hair colouring agents also makes people more prone to get bladder carcinoma.

•  Radiation 

If you have a history of exposure to radiation, it puts you in danger of developing bladder cancer.

• Chronic inflammation of the bladder

Chronic inflammation of the bladder is another well known risk factor for developing bladder cancer.  if you have past history of recurrent episodes of urinary tract infections or a past history of bladder stones, your bladder has been under chronic inflammatory process.

• High fat diet, fried meat animal fats
• Age - as with many cancers, your chances of getting a bladder tumor increases with advancing age. As you grow old, the cells accumulate mutations and finally can become malignant.
• White race
• Male gender - men are at three times more risk of developing bladder cancer than females
• Lynch syndrome

If you have any of above risk factors, you have chance of developing bladder carcinoma. It doesn't mean that every one exposed to above agents can develop bladder cancer. It also doesn't mean that you will not get bladder cancer if you don't have any of those risk factors. Therefore, there is no need to panic. But, you should be aware of symptoms of bladder cancer to identify it early.

The most common feature of bladder cancer is gross hematuria. Therefore, if you ever develop hematuria, even once in your life, you should immediately seek medical help. 

Why Pressure Flow Studies are preferred over Peak Flow Rate when diagnosing BOO?

Bladder outflow obstruction (BOO) is the combination of low flow rates in the presence of high voiding pressure. The symptoms of BOO can be vague and therefore, not reliable. For example, the patient may complain of poor stream, but it can due to low voiding pressure due to detrusor instability, neurogenic instability or due to poor bladder contraction. Therefore, to diagnose BOO both the flow rate and the voiding pressure should be measured at the same time.

Why Urologist Prefer LUTS over Prostatism?

LUTS – Lower Urinary Tract Symptoms

Not only males, but also females experience lower urinary tract symptoms as they grow older. Many think that the only benign prostatic hyperplasia is the only cause of these lower urinary tract symptoms, but it is not true. It can be due to several reasons. They include,

·         Neurogenic bladder dysfunction as a result of stroke, Alzheimer’s disease, Parkinson’s disease, diabetes and stroke.

·         Idiopathic detrusor overactivity.

·         Degeneration of bladder smooth muscle giving rise to impaired voiding and detrusor instability.

·         Bladder out flow obstruction due to benign prostatic hyperplasia. 

Therefore, a more descriptive term like ‘prostatism’ may not be appropriate to describe most of the lower urinary tract symptoms.

What is LUTS?

LUTS stands for lower urinary tract symptoms. These lower urinary tract symptoms are mainly divided into two categories. There are voiding symptoms and storage symptoms.

Voiding Symptoms

·         Hesitancy

·         Poor stream

·         Intermittent stream

·         Terminal dribbling

·         Feeling of inadequate emptying of the bladder

Storage symptoms

·         Frequency

·         Urgency

·         Urge incontinence

·         Nocturia

·         Nocturnal enuresis

Benign Prostatic Hyperplasia

Prostate gland is an important gland in the male reproductive tract. Its secretions contribute to the content of the semen. The exact effect of these secretions is not clearly understood.

The gland is anatomically divided into 3 zones. They are,

·         Periurthral transitional zone

·         Central Zone

·         Peripheral zone

The transitional zone surrounds the urethra. The peripheral zone and the central zone are best described as ‘egg in the egg cup’ where egg being the central zone. The transitional zone is the part that hypertrophies and gives rise to benign prostatic hyperplasia. The peripheral zone is the part from which most prostatic carcinoma arises.

Benign prostatic hyperplasia occurs in men more than fifty years of age. They have found out that 50% of men more than 60 years of age are having this condition. It is also the main cause of bladder outflow obstruction is men aged more than 70 years. 

With aging the testosterone levels gradually declines. Men also have some amount of estrogens in their body. These estrogens are secreted from the adrenal cortex. Even though the testosterone levels declines, the estrogen levels continue stay at the same level. Scientists think that this imbalance between testosterone and estrogen hormone levels is the reason behind the hyperplasia of the prostate. The high estrogen levels compared to testosterone  levels in the body cause the prostate glandular and stromal tissues to increase in number. 

Benign prostatic hyperplasia changes the urinary tract in several ways. 

·         It lengthens the urethra. Some times the urethra can be elongated to twice the length of its normal length.

·         The hyperplastic prostate gives rise to bladder outflow obstruction (BOO). As a result the bladder has to contract against a high resistant. This causes the bladder musculature to hypertrophy. The blood flow of the bladder also increases and the resultant veins in the base of the bladder are apt cause haematuria.