Achieving yet another milestone in medical excellence team of experts led by Dr. Mohan Keshavamurthy, Consultant Urologist & Transplant Surgeon, Fortis Hospitals Seshadripuram performed a complex kidney transplant. 30 year old Mohammed Abdul Ameer Mahadi from Iraq underwent his 3rd kidney transplant.

Ameer suffered chronic glomerulonephritis a common form of infection that affects the kidneys and suffered renal failure 10 years ago. He underwent his first kidney transplant 10 years ago and the donor was his father.  However within 5 years renal function worsened and he had to undergo a second transplant.  This time his elder brother was the donor.

“Ameer came to us with a third renal failure and kidney transplant was the only realistic option to preserve his quality of life. Since he had already undergone two transplants earlier and had four kidneys in his abdominal cavity, finding space for the 5th kidney was difficult. So our challenge was to first create a place which should be in the vicinity of the bladder. Normally transplant kidney is connected to the iliac artery and veins for blood supply .In this case both sets of iliac vessels were used up already. Hence we had to go higher in the abdomen to connect the kidney to the great vessels aorta & IVC. This will need extreme technical finesse considering the torrential blood loss if the anastomosis (vascular connection of renal artery & vein to Aorta & Venacava respectively) is not water tight. Besides the donor ureter will have to be longer to reach the bladder as it is farther away than the routine. Hence an extremely competent team of transplant surgeons & anesthetists were required besides a well equipped operation theatre” explained Dr. Mohan.
He also added, “We had to follow an extremely precise procedure as the existing transplant kidneys cannot be taken out as there is a pseudo capsule which is there around the kidney and it is practically not possible to take out the existing failed kidneys as the blood loss is very high and critically affects the patient during surgery and post operative period
The major issue in the above case was that the on table rejection is high in 3rd transplants. Hence careful medical preparation has to be made under the guidance of an expert nephrologist.

Following the procedure Ameer is doing well and passed 15 litres of urine in the first 24 hours after surgery. Within 36 hours post transplant the creatinine returned to normal level. Both the recipient and the donor are doing very well. This time the donor is his younger brother.
“It is all because of my family who has supported me throughout. Not only giving me the best of medical care and treatment but also donating their kidneys to give me a new lease of life. First my father then my elder brother and this time it’s my younger brother. It is because of my family and the excellent medical attention that I have received during my difficult hours that I am in front of you today. My immense gratitude to Dr. Mohan and his team and Fortis Hospitals who is behind the success of my healthy life today” said Ameer.

The prevalence of renal failure in India needing some form of renal replacement therapy (RRT) is 0.8 to 1.4 % of the population. 1.5 million people approximately need dialysis or kidney transplantation to prolong life. Only 10 % are provided with renal replacement therapy. We perform approximately 3000 kidney transplants a year which is 2 % of the eligible candidates. The critical lacunae are lack of cadaver organs & transplant centers.
Kidney disease is an urgent problem both nationally and worldwide. Our kidneys are vital organs which filter and clean our blood and excrete toxins, waste products and excess water as urine. People develop kidney disease for a wide variety of reasons. Sometimes it happens suddenly, and sometimes it comes on slowly over a period of time. Many people with mild kidney disease feel well, but in some people the kidneys get progressively worse and degenerate into badly scarred “end-stage” kidneys which no longer perform their normal function. When this happens the patients become more and more ill as toxins accumulate in their blood. When the kidneys stop working completely, the patient needs a kidney transplant or dialysis treatment to keep them alive. Although dialysis treatment does some of the work of the kidneys, people on dialysis have lifestyle restrictions, and are more likely to develop a number of other medical problems such as heart disease.

Quick Facts  On Kidney
Apart from clearing the blood of toxic waste, kidneys play a vital role in the control of our blood pressure,  bone integrity, cardiovascular and immune function, and production of red blood cells to carry oxygen around the body
Common causes of kidney failure are hypertension (high blood pressure) and diabetes
Statistics say the number of patients with End-Stage Kidney Failure increases every year by about 4 to 6 %
According to recent statistics from the World Health Organization (WHO), approximately 100,000 solid organ transplants are performed every year worldwide. Of this figure, 68,300 are kidney transplants, 19,900 are liver transplants, 5,200 are heart transplants, 3,250 are lung transplants and 2,800 are pancreas transplants. Overall, renal transplants account for almost 69% of all solid organ transplants, worldwide
The sad reality is that most cases of organ diseases are completely avoidable, with simple dietary and lifestyle adjustments, better control of diabetes, hypertension & heart disease.

“Procedure creates new bladder from patient’s own intestine”

~Doctors at Fortis Hospitals Bangalore performs a unique surgery to treat bladder cancer”

A team of specialist led by Dr. Mohan Keshavamurthy, Consultant Urologist at Fortis Hospitals has performed a unique surgery to help bladder cancer patients restore their normal urine function by avoiding the traditional method of uncomfortable external urine collection system. This unique procedure is called as neobladder.

Dr. Mohan & is routinely performing neobladder procedure whereby the patient’s own intestine is used to reshape and create a new pouch or artificial bladder replacing the damaged bladder. This artificial bladder made from the intestine performs the function of a bladder and the patient leads a completely normal life. In the traditional method surgeons used to construct an external pouch for urine collection and most of the time it was socially obstructing to carry a urine pouch.

Highlighting a success story of neobladder, Dr. Mohan cites the example of a successful surgery done at the hospital. Mr. Nadigar a 66 year old elderly man from Hubli was diagnosed of an aggressive variety of bladder cancer where the patient’s bladder had to be removed. He first got the symptom in America where blood used to flow in urine and then he came back to India to get it diagnosed which finally turned out to be bladder cancer.  He then consulted various doctors who all suggested him the traditionally old method of putting the pouch outside but Dr. Mohan gave him the confidence to undergo neobladder surgery which he successfully underwent the procedure replacing the diseased bladder and construction of an artificial bladder with the patient’s own intestine.

Explaining the procedure Dr. Mohan said “The human bladder has two basic functions: a reservoir to store urine and secondly, squeezing automatically, to empty the urine. Neobladder is actually a bag like structure constructed using the patient’s own intestine, and functions like a urinary reservoir. However it lacks contracting ability, and therefore the patient has to tighten his tummy muscles to squeeze and empty the neobladder. Some patients would be given a thin lubricated tube to empty the reservoir via the urinary passage.”

Traditionally, after removal of the bladder, patients would be given an external collection device for urine. This would be in the form of a special plastic pouch fixed to the lower abdomen by a sticker. This would require changing every few days or weeks when loose. Besides, bathing or any water-based activities would be impossible to prevent the sticker from falling off. Women would sometimes feel socially uncomfortable with this external appliance. On the other hand, a person with a neobladder would look and function completely normally.  Besides, the savings on the cost of buying these expensive imported pouches is enormous.

Dr. Mohan says that with age comes the risk of bladder cancer so one has to be more careful and early detection makes the treatment more beneficial. The risk of bladder cancer striking men and women is 1:1.

The word cancer spreads fear in our minds as we often feel cancer is incurable. But doctors at Fortis Hospitals say that bladder cancer is completely curable with early detection. Often the first symptom of bladder cancer is blood in urine, which is easily detectable and should never be ignored. Early bladder cancer can be removed endoscopically through the urinary passage. However, when the cancer spreads into the bladder muscles, the bladder itself has to be removed completely & may be replaced with a neobladder in suitable cases.

About Dr Mohan Keshavmurthy:

Qualification :MS, MCh ( Urology ) Fellowship in Uro Oncology

Medical Education Certification by the American Society Of Transplant Surgeons Fellowship in Renal & Pancreas Transplantation, Multiorgan Transplant Program QEII Health Sciences Centre, Halifax, Nova Scotia, Canada Fellowship in Uro-oncology, Tata Memorial Hospital, Bombay/M Ch (Urology) Seth GS Medical College and KEM Hospital, Bombay, INDIA /MS(General Surgery)KM School of Postgraduate Studies, VS Hospital/MBBS Bangalore Medical College, Bangalore, INDIA

Areas of Interest/Expertise

Laser  Urology/Onco Urology/Kidney Transplant Transplant/Andrology/Pediatric  Urology

Superspecialty Experiance r. Mohan Keshavmurthy is an eminent Urologist and Transplant Surgeon who brings 16 years of varied experience iUrologyn the field. Dr Mohan is an alumnus of Bangalore Medical College where he completed his MBBS degree. He completed his general surgical training in Ahmedabad at V S Hospital. He then did his urology at the prestigious KEM Hospital and was awarded the gold medal in urology for topping the exam conducted by Mumbai university. He was the first post Mch fellow in Urologynaec Oncology at Tata Memorial Hospital. He was the recipient of Rotary ambassadorial international scholarship and utilized the same for training in advanced urology and solid organ transplantation at QEII Health sciences center, Halifax, Canada.He has had further training in the form of travelling fellowships in Pancreas transplant & Uro oncology at various centres in the United States

Specialty Area of Expertise : Dr Mohan is a pioneer in the field of laser urology .He has performed over 250 laser TURPs and over 1500 laser fragmentation of kidney and ureteric stones. He has performed over 1600 kidney transplants and 75 pancreas transplants. He is an internationally known expert in complex reconstruction of the urinary tract and major uro oncological procedures in both adult and pediatric age groups such as Buccal mucosal Urethroplasty,Radical Prostatectomy,Radical Cystectomy with Neobladder,Redo Ureteric re-implantation,Boari Flap,Ileal Ureter,Partial Nephrectomy with Vascular control. He also has one of the largest series of implantation of flexible and inflatable penile prosthesis in Indian patients. He has over 100 publications and presentations in peer reviewed journals.

Academic  Achievements

1.Rotary International Ambassadorial Scholar, 1997 – 1998
2. Gold Medalist and University Topper in the M Ch. (Urology) examination for the year 1995 held by University of Bombay
3. Travelling Fellow of the Bombay Urological Society for the year 1995
4. Second Rank in All India Entrance Examinations for Super-specialty Courses, 1993
5. First Class – MS (General Surgery) Gujarat University
6. Recipient of National Merit Scholarship for years 1981 – 1993
7. Distinction in Pharmacology, Microbiology, General Surgery and Obstetrics & Gynecology
8. First Rank with Distinction – Premedical Junior College Examination

To get an appointment with  Dr Mohan Keshavmurthy, Please   email us at  enquiries@FortisHospitals.in

Those suffering from bladder cancer do not need an external urine collection system anymore. A team of specialists at Fortis Hospitals has performed a unique surgery to help patients restore their normal urine function.

Consultant urologist Dr Mohan Keshavamurthy who performs the procedure neo-bladder whereby the patient’s intestine is used to reshape and create a new pouch or artificial bladder replacing the damaged one.

This artificial bladder made from the intestine performs the function of a bladder and the patient leads a completely normal life. In the traditional method, surgeons used to construct an external pouch for urine collection.

Highlighting a success story of the neo-bladder, Mohan cited the example of a successful surgery done at the hospital. Natgir R K, a 66-year-old man from Hubli, was diagnosed with an aggressive variety of bladder cancer where the patient’s bladder had to be removed.

HOW IT WORKS

Explaining the procedure, Mohan said: “The human bladder has two basic functions: a reservoir to store urine and squeezing automatically to empty the urine. Neo-bladder is actually a bag-like structure made using the patient’s own intestine, and functions like a urinary reservoir. However, it lacks contracting ability, and the patient has to tighten his tummy muscles to squeeze and empty the neo-bladder. Some patients will be given a thin lubricated tube to empty the reservoir via the urinary passage.”

Traditionally, after removal of the bladder, patients will be given an external collection device for urine. This will be in the form of a special plastic pouch fixed to the lower abdomen by a sticker. This should be changed every few days or weeks.

Benign Prostatic Hyperplasia (BPH)

What is a prostate?

The prostate gland is part of the male reproductive system. It is about the size and shape of walnut. As pictured in the diagram, the prostate is located below the bladder and in front of the rectum. The prostate surrounds a tube called the urethra that carries urine from the bladder out through the penis. The main function of prostate is to produce fluid for semen.

Benign prostatic hyperplasia is a nonmalignant enlargement of the prostate and is the most common benign tumor in males, requiring 1.7 million physician office visits each year and results in more than 300,000 prostatectomies.

The prostate weighs only a few grams at birth but undergoes two different growth cycles during the life span of the average male. First at puberty the prostate undergoes androgen-mediated growth and reaches approximately 20g by age 20 . It remains this size until about the fifth decade of life when it undergoes a second increase in size in the majority of males.

BPH  will affect men starting in their forties and will increase so that by the time men are in their seventies, 90% will have some degree of prostatic  hyperplasia.

Etiology

The exact cause of prostratic hyperplasia is not known. However, two clear criteria necessary  for the occurrence of prostatic hyperplasia are an increase in age and the presence in testes. The androgen that mediates the growth of the prostate at all ages is dihydrotestosterone (DHT), which is formed within the prostate from plasma testosterone. As men age, the production of estradiol increases in relation to other androgens.

Symptoms

The symptoms of BPH are those associated with obstruction or irritation of the posterior urethra. These symptoms may include frequency, nocturia, dysuria , hesitancy in initiating voiding , dribbling after voiding, diminution of the caliber and force of the urinary stream, the sensation of incomplete emptying , and finally urinary  retention. Early on in the disorder the symptoms may be minimal due to the compensatory effect of the musculature of the bladder. However, as the disorder progresses symptoms will worsen.

Diagnosis

The initial evaluation of a patient with these symptoms should include a detailed history focusing on the urinary tract. Symptoms may also be quantified with the use of the AUA Symptom Index. A digital rectal exam should also be performed at this time for characterization of the size, consistency , and shape of the gland . It should be noted that the size of the prostate does not always correlate with obstruction of the urethra and often a seemingly small prostate can produce symptomatic obstruction.

There are a variety of tests available to the practitioner in the evaluation of prostatic hyperplasia. It should be noted however that although these tests may help to quantify a patient’s condition they are often not indicative of symptoms.

Treatment

Current treatment strategies for BHP  are dependent on the severity of the patient’s symptoms . Patients with mild disease benefit most from conservative monitoring . If symptoms progress patients may receive medical therapy for there symptoms. Patients with mild diseases benefit mostly from conservative monitoring. If symptoms progress patients may receive medical therapy for their symptoms .

What are the various Treatment Choices

Treatment choices for Benign Prostatic Hyperplasia

Watchful waiting: If you have no symptoms are not bothered by your symptoms or have moderate or severe symptoms but have not developed other urinary tract problems you may choose to visit your doctor once a year or sooner if you conditions changes. If your symptoms  becomes worse talk to your doctor about other treatments

Medical Treatments for Benign Prostatic Hyperplasia :

Two types  of medications may help relieve the symptoms of BPH . In some cases these medications may be combined together

Drugs that help relax the muscles of the prostate .These drugs are called alpha blockers .They include Tamsuloson, Alfuzosin,Doxazosin and Teraosin .Although all four drugs work equally well there are slight differences in the side effects of each one

Drugs that hep the prostate to shrink. These drugs are inhibitors of the 5  Alpha reductase  enzyme and include finasteride and dutasteride .,Your Doctor  may recommend this type of drug if you have an enlarged prostate . You will need to see your doctor on a regular basis if you take this drug. Because these drugs change as a result of your PSA test by lowering it about 50% (for example from 4 to about 2 or from 6 to about 3) this test may need to be repeated while you take this drug

Combination therapy; if you have an enlarged prostate and bothersome symptoms of BPH,you may be treated with combination fo both alpha blockers and drugs that shrink the prostate.

Minimally Invasive Treatments:

These treatments  are performed as outpatient procedures and may cause pain and discomfort that are relieved with the administration of an anesthetic .

After the treatment a catheter is placed in the bladder and remains for a few days while you are at home . In general these treatments are better at relieving symptoms than medical therapies but are less effective that surgical procedures

Surgery :

Symptoms may be selected as initial treatments if you have symptoms are particularly bothersome or you have developed other serious problems because of BHP.   You may also select surgery if you have tried medical or minimally invasive treatments and they have not been successful .The choice of surgery should be decided based  on your levels of discomfort, your medical tests results and your doctors suggestions

Transurethral resection of the prostate ( TURP )

This is the most common surgical procedure to treate symptoms of BPH. The procedure involves surgically removing inner portion of the prostate. Under anesthesia the surgeon uses a scope through the Urethra, so that there is no external scan

Urological Services  at Fortis Hospitals : Surgical Levels of Procedures

Level 7

Cystectomy Radical with continent pouch

Prostatectomy Radical

Level 6

Nephroureterectomy radiacal

Radical cystectomy with ileal conduit

PCNL 2 sittings

Reconstructive Urology Surgery( complex)

Level5

Adrenalectomy

Pyeloplasty

Nephrectomy Radical

Pyelo and Nephrolithotomy

Penile prosthesis

TURP 2 sittings

PCNL 2 Track

Urethral Reimplantation

Pyelolithotomy extended

Urethroplasty proximal

Level 4

PCNL single puncture

TURBT

Prostatectomy open

Urethroplasy open

Pyelolithotomy

URS middle or upper 3rd diseases

TURP

Level 3

AV Fistula elbow

Varicocele Ligitaion ( Bilateral )

Fulguration PU valve

VIU

Ileal Conduit

Ureterolithotomy

Orchidopexy Bilateral

URS and Dj Stenting
Penile Chordee Correction

URS lower 3rd calculus diseases

PCN

URS –Uretoerotomy

Remnal Cysts Excision

TURBT small

TUIP

Level 2A

Bladder Stone Surgery Open

DJ Stenting

AV Fistula(wrist)

Orchidopexy Unilateral

Bladder stone Lithotripsy

VUR Injection

Level 2

Bladder Biopsy for CA Bladder ( TUR biopsy )

Cystoscopy plus RPG

Bladder stone extractions

Epidedectomy

Cord Swelling excisions

SPC

Cystoscopy plus hydrodistension

Varicocele ligation unilateral

Level 1A

Circumcision

Meatoplasty

Cystocopy with Cold Cup Biopsy

Prepuceoplasty

Cytoscopy under anesthesia

Testicular biopsy

Cytoscopy plus OTIS

Vasectomy

Level 1

Cytoscopy

SPC in OT

EUA

Trucut biopsy of Prostate

Meatotomy  (Urethral )

Urethral Dilatation

Penile Biopsy