Percutaneous nephrostomy

PERCUTANEOUS NEPHROSTOMY, Clinical Skills Lab

INTRODUCTION:

Percutaneous nephrostomy is an insertion of a tube into the pelvi-calyceal system to allow diversion of the urine output.  This can be  a life saving procedure when the urinary tract (usually the ureter) is obstructed with sepsis.  Putting a percutaneous nephrostomy would relieve the kidney failure as well as the underlying sepsis, both of which can be fatal. 

The common causes of ureteric obstruction include: obstruction by cancers e.g. cancer cervix, rectal cancers, metastatic disease to the retroperitoneal lymph nodes. 

Benign causes include ureteric strictures or fistulas, often iatrogenic, caused by the gynaecologists during surgery on the uterus.

Percutaneous nephrostomy is an expert procedure, usually done by the interventional radiologist or by the urologist. It is often done with the imaging by ultrasound and fluoroscopy. The pelvi-calyceal system should ideally be dilated to reduce the risk of injury to the kidney.  A suitably dilated calyx is punctured. This is usually the lower calyx to reduce the risk of injury to the pleura when the upper calyx is punctured.

Informed consent is important to get the patient’s cooperation and also to inform the family of the risk of the procedure including bleeding, injury to the nearby structures including the pleura and intestines.  The procedure is done after infiltration of the skin and tract with local anaesthesia. The dilated calyx is punctured with a percutaneous needle, usually an 18G puncture needle under ultrasound guide and tracking.  After the needle has entered the dilated calyx, urine is withdrawn and sent for bacterial culture.  A guide wire is introduced down the needle into the renal pelvis or  the upper ureter.  The tract is then dilated, usually 6 Fr, 8 Fr, 10 Fr serial dilators.  The percutaneous nephrostomy tube, usually 10 or 12 Fr is then inserted over the same guide wire into the pelvi-calyceal system to drain the urine. The percutaneous nephrostomy usually has a pigtail to reduce the risk of dislodgement from the pelvi-calyceal system.  The nephrostomy is also anchored with Silk sutures to the patient’s skin. The nephrostomy is then connected to a drainage urine bag.  Nephrostomy tubes can usually be left insitu for up to 6 months, although usually for much shorter. In the meantime, the underlying problems can be managed, e.g. radiotherapy for cancer of the cervix.

FOLLOW-UP:

If the urinary drainage is still required, the nephrostomy tube can be wired with a guide wire and if the guide wire can pass into the bladder, the nephrostomy tube can be changed to an indwelling ureteric stent. Again, this is done under fluoroscopy. 

Dr Clarence Lei Chang Moh, FRCS Urol

Consultant Urologist

email: clarencelei@gmail.com

10^th September 2013

illustrations in another document

Diet Stones

Renal Mass腎臟問題

Large solid vascular renal masses are usually cancerous. Such patients may present with  haematuria but many masses are picked up earlier at health screenings. There is however, no role for routine screening for renal masses except in those with such a strong family history or previous history. An incidental mass of the right kidney at the  lower pole, 5 x 4 cm is such an example. The standard practice nowadays is to have another imaging modality to confirm the ultrasound findings, especially any tumour thrombus in the renal vein and IVC.  The CT can also help to look for any para-aortic lymphadenopathy The commonest benign renal masses viz AML angiomyolipoma and oncytoma may exhibit characteristic lesions on CT. I will also do a chest x-ray at the same time.


One option is to do percutaneous ultrasound guided Trucut biopsies of the lesion.  However, the limitation of this is that  the  biopsy may not be representative of the tumour as renal cell carcinoma is heterogenous.  Biopsy can also cause bleeding and associated with the theoretical risk of biopsy tract seedling. One would also require a good uro-histopathologist to make a diagnosis. I would usually recommend a biopsy if we are thinking of systemic therapy without a nephrectomy, e.g. in the presence of metastatic disease.


One option is to remove the entire kidney with the tumour, for completeness of the surgery.


However, I would think the standard management would be a partial nephrectomy.  Partial nephrectomy is more complicated than total nephrectomy. It requires control of the renal vein, renal artery and probably
the insertion of ureteric catheter so that methylene blue can be  injected to detect any breach of the pelvi-calcyeal system which needs to be sutured. As the surgical margin  is renal tissue, there is also an increased risk of secondary haemorrhage, in addition to urinary fistula.  As with most surgeries, it can be done by three approaches: open, laparoscopic or robotic.  The later two usually takes longer.


“Minimally” invasive therapy includes cryoablation and radiofrequency. These ablative energies may be applied percutanously under ultrasound guide or laparoscopically. Tumour destruction is still incomplete. However, I would recommend such “MIT” only to patients who are unfit for surgery or who has
multiple bilateral lesions  where surgery is difficult.


The approach in small (<4cm) renal masses (SRM) is more conservative, which may include active surveillance in masses <3cm (incidence of primary metastatic disease 2.4 % compared to 8.4% if mass is 3-4cm)

Dr Clarence Lei Chang  Moh, FRCS Urol
clarencelei@gmail.com
20 Jan 2012

B P H , BENIGN PROSTATEHY PERPLASIA（良性前列腺增生症）

B P H ,  BENIGN  PROSTATEHY  PERPLASIA


BPH can cause obstructive urinary symptoms eg h e s i s t a n c y ,   p o o r   a n d  
i n t e r m i t t e n t   u r i n e   f l o w ,   t e r m i n a l   d r i b b l i n g   a n d   r e t e n t i o n .


Modern  practice would require that the urine flow be documented with a
uroflowmetry. A normal uroflowmetry is >15 ml/sec.  The post void residue
should also be <100 mls for most patients and any post void residue >300 mls
would be considered as having chronic retention with a risk of
hydronephrosis.

TWO types pf medicatons are used to treat BPH.
For patients whose prostate are proven to be enlarged (> 40 cc on rectal
exam or ultrasound per abdomen or transrectal TRUS), they will require a
medication  to reduce the size of the prostate gland.  This is done by
decreasing the dihydro-testosterone inside the prostate with  A v o d a r t
(Dutasteride) or Proscar (Finasteride) daily.  It takes 6 months to show any
clinical benefit.  He will have to take this on a long term basis, possibly for
many years, until a better agent comes along.   This agents cost about RM7
per day.

To improve his uroflow quickly (days) , one can use an alpha-blocker to relax
the adrenergic nerves to the prostatic urethra. The available ones include
Harnal (Tamsulosin),  X a t r a l (Alfuzosin), Hytrin (Terazosin), Cardura
(Doxazosin). The side effects  are those of postural hypotension and
ejaculatory disturbance.  The cost range from RM1 to RM4 per day.

Other symptoms may not due to the prostate but from an overactive bladder,
OAB.  These symptoms include f r e q u e n c y ,   n o c t u r i a ,   a n d   u r g e n c y. In
such cases, an anti-cholinergic would be more useful e.g. Detrusitol
(Tolterodine or V e s i c a r e (Solifenacin).
If there is pain,one should exclude an UTI or stones.


If there is gross hematuria one need to exclude a bladder or renal tumour.
Bladder outlet obstruction and overactive bladder may be associated with
erectile dysfunction, ED.  Many of these patients would also benefit from
PDE-5 inhibitor (phosphodiiesterases type 5) e.g. Sildenafil (Viagra),
Vardenafil (Levitra) or Tadalafil (Cialis).  Sildenafil is now available as a
generic from Ranbaxy at just over RM10/- per table when the original Viagra
is about RM45/-.  US FDA also recent approved d a i l y   d o s e   o f   T a d a l a f i l
5 mg to be used for both erectile dysfunction and bladder outlet obstruction.

A further factor to improve patients with lower urinary tract symptoms is the
possibility of adding on testosterone hormonal replacement. A clue to such a
disorder (TDS, Testosterone Deficiency Syndrome) is that the patient has
other aspects of the metabolic syndrome e.g. obesity, hypertension, diabetesas well as  loss of libido, erectile dysfunction, general tiredness. The biochemical diagnosis of TDS is finding a total testosterone of <11 nmol/ml. They can now be very effectively treated by intramuscular injection of
N e b i d o  1 gm every 3 months.

Thank you very much for your attention.

Dr Clarence Lei Chang Moh
Consultant Urologist
e-mail: clarencelei@gmail.com  
13 January 2012

Ref:

Benign prostatic hyperplasia
(Diagram taken from http://en.wikipedia.org/wiki/Benign_prostatic_hyperplasia

Diagram illustrating normal prostate (left) and benign prostatic hyperplasia (right).

UROLOGICAL CONDITIONS IN CHILDREN

UROLOGICAL CONDITIONS IN CHILDREN
by Dr Clarence Lei, FRCS Urol, Consultant Urologist, email: clarencelei@gmail.com

INTRODUCTION:
The scope of discussion will include the clinical presentation, the medical
treatment, the timing and a brief description of any paediatric urologic surgery required.

UROLOGICAL CONDITIONS in children include: circumcision, undescended testes (UDT),
scrotal swellings including hydrocele and hernia, acute scrotal pain incl torsion, hypospadias. A
dilated urinary tract is the commonest antenatal diagnosis and the causes include: PUJO, pelvi-
ureteric junction obstruction, VUJO, vesico-ureteric junction obstruction, VUR, vesico-ureteric
reflux and PUV, posterior urethral valve. Neuropathic bladder is also increasingly an important
cause of dilated urinary tract. Finally, urogenital tumours include those of the kidneys (Wilms),
testes and the rare rhabdomyosarcoma of the prostate.

The commonest medical indication for circumcision is phimosis, as manifested by ballooning
of the prepuce at micturation. Circumcision has also been shown to reduce the incidence of UTI,
urinary tract infection and probably viral infections (including HIV) of the male and the female
partners (later). Paraphimosis in a young boy is a surgical emergency.

The incidence of undescended testes at birth is 10% and this decreases to 1% at the age of 1 year.
Bilateral undescended testes can be occasionally treated by injection HCG. After the age of 1
year, any undescended or ectopic testes require surgery as soon as possible. Complications
include torsion and associated hernia. In adolescence, the testes can undergo malignant change.
Hence, orchidopexy and testicular self examination are important health education for testicular
maldescent. Hernia in children should always be operated as soon as possible to reduce the risk
of strangulation requiring emergency surgery. Persistent increasing hydrocele after the age of 1
year can also be operated electively via an inguinal approach so as to do a herniotomy at the same
time. I routinely drain the hydrocele as well.

Acute scrotal pain is testicular torsion unless proven otherwise. Such proof may be in the
form of diagnosis of torsion appendix testis or an inflammation as evidenced by urgent doppler
ultrasound, which can occur in 50% of children with scrotal pain.

Bilateral antenatal hydronephrosis in a male child is often due to PUV, posterior urethral valve.
Ultrasound would also indicate a distended and thickened bladder. PUV associated with sepsis
(often introduced during an MCU !) and renal impairment are best treated by a vesicostomy.
Where facilities are available including paediatric cystoscope, the PUV can then be fulgurated
with closure of the vesicostomy electively.

Bilateral hydronephrosis without renal impairment in the female and all unilateral
hydronephrosis can be treated electively. Ultrasound can be done within the first week of
delivery and functional study about 6 weeks later, when the kidneys have achieved some
maturity. The appropriate functional study for the kidneys is an isotope scan (usually Tc labeled
MAG-3) to see the differential function and the drainage of the dilated system. Many such
asymptomatic hydronephrotic system improves as the child grows older. It is realised nowadays
that only about 30% of such patients require surgery. The indications of surgery would be
increasing dilatation and deterioration of function on serial isotope scans (e.g. decreased to 30%).
The standard treatment would be an excision of obstruction and a pyeloplasty.

The current treatment for vesicoureteric reflux is to give a therapeutic dose of antibiotics
urgently when there is a febrile UTI. Long term prophylactic antibiotics and surgery is now
recognised as not improving the long term outcome. There is an increased usage of cystoscopic
Deflux injection of the ureteric orifice to reduce the incidence of febrile UTI. High grade reflux
tends to have more febrile UTI and therefore more interventions with injection therapy.

Where the urinary tract dilatation is due to a duplex system, a definitive treatment would be
surgical excision of the hydronephrotic poorly functioning duplex moiety. Neuropathic bladder
can be closely monitored with ultrasound, radio isotope study and referral for urodynamics,
if there is any deterioration. High pressure bladder can cause renal failure and such bladders
are best treated with cystoplasty (often a “clam” type) followed by CIC, clean intermittent
catheterisation. Urinary stones are occasionally seen in children and treatment is similar as
adults, namely, by ESWL, extracorporeal shockwave lithotripsy or by endourology.

Hypospadias occurs in 1 : 300 of newborns. The main aim of surgery is to enable the child to
pass urine standing up and also to have a penis straight enough for eventual sexual relations.
The recommended age for surgery is after the age of 1 year (unless the penis is very small) and
to finish surgery before the child goes to school. There are many techniques for hypospadias
surgery and most requires the patient to have some kind of catheter for at least a week. They will
often require a second stage operation.

CONCLUSION:
The medical personnel and parents should also know the common complications and
outcome of the conditions. The referral mechanism and the follow-up protocol depend on the local
facilities.

A speech

Good Evening, Ladies & Gentlemen; 

may I have ur  attention please.

A special good evening to  Mr David Tolley, 

President of Royal College of Surgeons, & Mrs Tolley;  

Good evening also to Mr Sam McClinton, Past-President of the Scottish  Urological Society n Lead Examiner,  & Mrs McClinton,

This is not a formal dinner  but it is still good to say a few words at an important  gathering like this.

The Sarawak Club was founded in 1876 by Sir Charles Brooke, who was the second white Rajah of Sarawak.   

Sarawak was a separate state by itself: in fact  u may have noticed that one still need a passport to enter Sarawak! 

A surgeon,  Dr  MacDougall founded one of the earlier hospitals  in Kuching.  His wife founded a famous school very near to Pullman hotel, the St Mary’s school, where my wife, Ivy   Chin has been a senior teacher for > 20 years.  She is also responsible for this dinner!

I went Edinburgh to work under the late Professor Chisholm and Mr Tolley , to learn some urology!  It was in 1988  n 89. 

NOW EDINBURGH HAS COME TO KUCHING, HOPEFULLY ON A YEARLY BASIS !! Indeed there WAS ALREADY   a long tradition of  collaboration. While in Edinburgh I also had to report to the late Sir James Fraser who was the Post Graduate Dean of the College.  I discovered that he worked as a surgeon in Sarawak for many years, in his young days.

Malaysia, especially Sarawak is  peaceful with friendly people, wonderful patients. We are lucky  that the College with the help of Professor Khin Tun brought the MRCS exam here.  I understand that > 80 candidates applied and >half passed the recent exam  It is obvious that an Edinburgh  Royal College qualification  is  held in high regard in many parts of the world.

I want to welcome three special guests tonight: Dr John Chew, the Chairman of the Sarawak state Malaysian Medical Association & Dr Peter Wong , Secretary of the Malaysian College of Surgeons.  Thank you for the honour, Dr John Chew & Dr Peter Wong. We also have Dr Donald Liew, a young neurosurgeon at GH whom I hope can help us in the exam nest year!

Please enjoy the rest of the dinner and I hope we do meet again.

Dr Clarence Lei, clarencelei@gmail.com

MEN'S HEALTH - ED, Erectile Dysfunctio

HOW COMMON IS ED?


Men's health has been a neglected component of community health care.  There are many
programmes for the children and women; indeed many are sponsored by the State.
Erectile function is an important component of men's health and can be a strategy to
improve the provision of men's health.  Erectile dysfunction or ED is defined by the
National Institute of Health, U.S.A. as the persistent inability to initiate and/or maintain
an erection of the penis sufficient to permit satisfactory sexual intercourse. The term
"ED" is referable to "Impotence" because impotence implies a hopeless situation.
According to established epidemiology surveys, at least 10% of men have ED. However,
ED can be mild, moderate or severe. This figure rises to at least 50% in special risk
groups, e.g. patients with diabetes or moderate hypertension.

WHY BOTHERS WITH ED?
In the Asian community, ED is still a taboo subject, even with doctors.  It is well known
that ED impacts severely on the quality of life.  The ED patient typically suffers from the
following: guilt, depression, anxiety, frustration, low self esteem.  The partner may feel
rejected, thinking that the husband no longer desires her or is having an extra marital
affair.

WHAT CAUSES ED?
Although there is an inevitable psychological component with ED, most ED patients have
an underlying physical cause.  Patients should not seek treatment for ED in isolation.
The underlying causes should be treated:
• Arteriosclerosis or hardening of arteries.
• Hypertension.
• Diabetes.
• Heart disease.
• Neurological disorders.
• Neurological diseases.
• Diseases of the lower urogenital tract, e.g. cancer prostate, penile deformities.
• After pelvic surgery.
• Certain medications.

WHAT LIFESTYLE CHANGES CAN YOU MAKE TO DECREASE ED?
Obviously, a healthy lifestyle contributes to many of these diseases as well as to ED
itself.  This will include the following:
• Quit smoking.
• Reduce consumption of alcohol.2
• Exercise.
• Reduced obesity.
• Diet modification to reduce high cholesterol or triglycerides.
• Adequate relaxation and rest.
• Better communication with your partner.

HOW DO YOU ASSESS ED?
Depending on the severity of symptoms scored on the International Index of Erectile
Function (IIEF), ED can be classified as mild (score 12-21), moderate (score 8-11) or
severe (score 5-7).  The incidence of erectile dysfunction in Malaysia has been studied by
the National Family Planning and Development Board and is very similar to the
Massachusetts Male Aging study in U.S.  It is also age related. Briefly, 50% of men at 50
years of age have ED, 60% at 60 years and 70% at 70 years.


International Index of Erectile Function (IIEF)

Answer these questions if you are concerned about Erectile Dysfunction.

WHAT TESTS SHOULD BE DONE TO ASSESS ED?
In addition to a detailed medical history and physical examination (including DRE,
digital rectal examination of the prostate), certain tests can be done.  The urine
examination and blood sugar assessment is usually done.  If the patient also suffers from
a loss of libido (desire for sex), blood may be taken to check the hormonal profile
(namely, total testosterone and prolactin).  Depending on the underlying pre-existing
medical illnesses, blood for cholesterol, kidney function, liver function may also be
tested.  If the patient also has urinary symptoms, then other aspects of men's health (e.g.
urine flow rate and blood for PSA  or prostatic specific antigen) may be done.  In
exceptional cases, detailed evaluation may be done and this includes colour doppler study
of the blood flow to the penis and to test for nocturnal penile tumescence (NPT).
WHAT TREATMENT ARE AVAILABLE FOR ED PATIENTS?
Sildenafil (trade name, Viagra) was introduced in Malaysia in 1999 and that
revolutionised the treatment of ED.  Prior to that, the main treatment for ED was to inject
a drug into the penis to cause vasodilatation and erection.  If that fails, then the main
treatment was to surgically insert a penile implant.  In early 2004, the patients have a
choice of two new oral medications for ED, namely, Tadalafil (trade name, Cialis) and
Vardenafil (trade name, Levitra).  These drugs enhance the penile erection when a person
is sexually stimulated but the erection is not sufficient for sexual activity.  Penile erection
occurs when nerve stimulation causes the release of chemicals in the penis which in turn
causes dilatation of the vessels.  This group of oral medications block the breakdown of
these chemicals (called vasodilators) and therefore help to enhance the penile erection.
These drugs work only when the erection is insufficient for sexual activity and not if the
erection is normal.  If the erection is already normal, the vasodilator receptors are used up
and taking these oral medications will not enhance a normal erection.
WHAT DO PATIENTS EXPECT FROM THE ORAL MEDICATIONS?
The oral medications are remarkably effective and the effectiveness range from 80% to
about 50% in more severe cases.  Patients have to see their doctors to see the underlying
cause of their ED as well as to discuss treatment expectations.  For those patients whose
initial treatment with oral medication fails, further tests may be necessary.

WHAT ARE THE SIDE EFFECTS OF ORAL MEDICATIONS FOR ED?
As with all medications, there are some side effects.  These drugs cause increased blood
flow to the penis and to some other parts of the body as well and therefore, can cause a
drop in the blood pressure.  If patients are taking a class of drugs called nitrates for chest
pain, then it is an absolute contraindication to the taking of these 3 types of oral
medications.  In addition, these 3 medications cause side effects which are mostly related
to dilatation of blood vessels, namely:4
• Facial flushing.
• Indigestion.
• Backache.
• Headache.
• Nasal congestion.
• Dizziness.
The side effects are mild and transient.  If they persist, this usually means that the patient
has to decrease the dosage of the oral medication.  These 3 oral medications have been
proven with a high level of scientific evidence by doing double-blind placebo controlled
clinical trials to be effective.  This is unlike most of the traditional medications or fake
products which are touted in the market or Internet.  It is therefore important to get such
expensive medications from a quality assured outlet, e.g. Normah Medical Specialist
Centre.

HOW ARE THE MEDICATIONS TAKEN?
The 3 types of medications are taken on an as required basis.  The duration of action is ½
hour to 4 hours (Viagra and Levitra) although one of them can last up to 36 hours
(Cialis). Cialis and Levitra may be taken with or without food.
SUMMARY:
Assessment and treatment for ED is an important avenue for improving men's health.  For
many, treating ED is just as important as treating underlying medical illness and adopting
a healthy lifestyle.

Dr Clarence Lei Chang Moh, FRCS Urol, FEBU, FAMM
Consultant Urologist
Feb 2004