Urology-a challenging specialty: Memoirs of an old urologist


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Urology-a challenging specialty:
Memoirs of an old urologist

Prof. Dr. Altaf Husain Rathore, FRCS
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By modern definition some people will not consider me a urologist because a urologist must be a full time specialist only practicing in urology, especially endoscopic surgery like T.U.R.P. and T.U.R.T. When I did my fellowship in surgery in 1966 there was no separate examination for these surgical specialties like urology, orthopedics, neurosurgery, trauma etc. and all were included in F.R.C.S. in general surgery. Urology was not so much developed even in U.K. and its special units existed only in teaching hospitals. At home Prof. Ismat Anwar was the first urologist at Lahore followed by Prof. Fatah Akhtar and Prof. Farah Khan, and at Karachi Prof. Adeeb Rizvi, who happened to be my class fellow in M.B.B.S. Beside 25% of my surgical practice consisted of urological problems.

The greatest problems a urologist faces are congenital anomalies like hypospadias, ectopic vesicle; enlarged prostate, stricture urethra, U.T.I., urolethiasis etc. Lately a new specialty has cropped up called nephrology which has made the job of a urologist slightly easier but still he has to deal with most of the genitourinary problems. Now let me share with the readers my life long experience in this specialty.

Circumcision: It is the smallest, the most common operation done in the Muslim and Jewish world. I used to do this operation when I was a third year M.B.B.S. student in 1957 and still I have to do it. Still I am scared during this operation because I have seen so many complications after circumcision done mostly by quacks like haemorrhage, even damage of glens penis. Any how people are usually not happy-either you have cut too little prepuce or cut too much foreskin and penis has become smaller or looking crooked. That is why so many clamps have been devised but none of them are entirely satisfactory. I personally use time tested bone cutter for the babies, Up to 6 month of age under ring block. In older patients I insist upon general anaesthesia and suturing it with C.G.30 sutures.

Hypospadias: The glandular and coronal types do not need any repair. The repair of perineal or scrotal or penile types is a real venture when it is accompanied by chordee. So many techniques have been described. I used mostly scrotal or prepuce flap and try to repair in one stage but it always hounded me with complications like multiple urinary fistula, stricture, incontinence of last drops of urine, even hair growth and stones in urethra. So one stage ends up in so many stages. I have come to the conclusion that it should be repaired in two stages.

Ectopia Vesicae: These unfortunate children with atrophy of the bladder have no hope for continent bladder. Some urologist recommend simple repair of the bladder and epispadias and do the self catheterization through out the life which I don’t think is practicable.

I always had been doing reimplantation of ureter in the sigmoid colon with the excision of bladder wall and correction of the epispadias. I always instruct parents to be vigilant about the U.T.I. and acidosis. Still I have seen some neglected children dying of acidosis and renal failure. Lately I saw one patient who came to me 20- years after his operation with the persistent incontinence of semen.

Male pseudohermaphrodite: In our society every body wants a male child or become a man. Most of these cases of intersex have all the characters of males except the development of phallus. As one of my friend Dr. Bous used to say that it is easier to convert them to a female than a male. Reconstruction of a functioning penis is very difficult. Old method of transfer of pedicel graft through the intermediate host is too time consuming and cumbersome. I have reconstructed about 40 penises by one stage groin or rectus abdomens myocutaneous flap. The main problem is the construction of urethra up to the tip and stiffening it. I never got luxury of using Scot’s inflatable prosthesis which is too expensive even for American. I used to put in silastic slabs of cartilage which were available locally and cheap. Later on when the synthetics were not available then I had to put in a bone graft taken from upper tibial shaft, even fibula. I never used rib or cartilage as they are crooked and had the reputation of getting absorbed. In my opinion the prosthesis in smaller penis of about 3 inches is more successful than longer ones. I think the Chinese technique of reconstruction of penis from the hand and fore-arm flap based on radial artery is the most successful than all other techniques.

Horse shoe kidney: Once I operated and reported 21 cases of horse shoe kidneys. I believe that two sides should be separated by dividing isthmus to avoid damage of the kidneys. I have never seen aneurysm of the abdominal aorta in either of the cases as has been reported in the literature.

Enlargement of prostate: Man always has dreamed of finding some drug for the treatment of benign enlargement of prostate or at least for its prevention. I remember when I was working as a consultant surgeon in a Roman Catholic Mission Hospital in 1969, a priest of about 55 years from the near by church was brought to me for prostatic symptoms. Fearing he may not get retention I gave him some testosterone tablets as prophylaxis. Next weak hospital superintendent who happened to be a nun, an old European lady doctor approached me and requested to stop that treatment because that priest started. chasing the female staff of the compound. Anyhow it was thought at that time that testosterone shrinks the prostate. Later female sex hormones like estrogens or progesterone were used for this purpose with out much success. It was just incidental that some alfa one adrenoreceptor blocker by the name Prazocin used for hypertension found out to relieve the symptoms of benign prostatic hypertrophy so that was the discovery of Terazocin Alfuzasin Doxazosin and Tamsoline became available in the market. There was also a break through by the discovery of finasteride for the shrinkage of the prostate. No doubt these two groups of medicines improve the symptoms of prostatic enlargement but it is not absolutely fool proof treatment of B.P.H. After successful treatment old people become resistant to them after few years and demand for operation. In view of the increasing the longevity of life we get more cases of B.P.H. who become refractory to the conservative treatment and demand for operation at the age when they are medically more unfit for the surgery. So I feel that instead of conservative treatment for the comparatively younger fit old people, it should be reserved for the unfit elderly person or people with mild prostatic symptoms. The fit people should be primarily be treated by surgery. Which operation? Oldest was Fryer’s. Other are Wilson-Hayes, Harris, Young’s perineal) and T.U.R.P. I had been performing perineal prostatectomy for extremely unfit patients but this technique is not acceptable for the patients and it has no special benefit than T.U.R.P. No doubt T.U.P.R. is a gold standard of prostatic enlargement but this instrument is not available everywhere in periphery, so more prostatic operations are done by open methods in Pakistan; Thanks God carcinoma of prostate is reported to be not so common in our country.

Urolethiasis: This disease is as old as the history of human being. It is a universal disease and is present even in some animals. Bladder stone were common in the past, so was the vasicolithotomy, the commonest operation in the medieval past. Lot of mechanical lithotripters was devised in the past to break and extract the bladder stones. When I came back to Pakistan after my fellowship, I digged out the old lithotripters in the dumps of the medical stores of District Headquarters Hospitals. Some of them were in excellent condition. So I started using them with great success. Though it was a blind procedure but I took the help of a cystoscope to see how much was left. The greatest problem was in children, very big and hard stones, By chance I managed to get a Russian shock wave endoscopic lithotripter which solved my problem of hardness and big size. Later on more refined endoscopic shock wave litholipter were available which made the life easier. Yet they were expensive and the procedure took lot of time so most of the surgeons remove the stone bladder by open method. Kidney stones are found every where in Pakistan but more common in south Punjab and interior Sind. The biggest stones in kidney I ever found were in Bahawalpur. Both Kidneys were clogged with stones; some times I wondered how the patient was alive. Operative treatment was and is the standard treatment. Lots of hopes were attached to sound wave lithotripsy (E.S.W.L.) in the beginning but it was found out that it was not a solution for every stone. It is a very expensive machine and has its limitation and is not acceptable to every patient. The procedure has been repeated few times to complete the pulverization of the stone. So the surgeon’s knifes is the best option.

Injury of urethra and ureter: Rupture urethra especially the membranous is still a real problem. After trying all sorts of procedures I have come to the conclusion that old fashion primary rail road-two bougies method of retaining a urethral catheter is still the procedure of choice. Stricture will develop in any case even you simply do suprapubic cystotomy. But this procedure will ensure the continuity of urethra. For injury of ureter especially during gynae operation the reimplantation of the ureter into the bladder by Baori’s technique is the best option in my opinion. Stricture urethra whether traumatic or inflammatory hounds every surgeon and urologist. Open repair or endoscopic urethrotomy has not given much satisfactory results. Most of the patients come for regular dilatation.

Urinary Tract Infections: Once urinary tract infection was a common problem. Sulpha group was ideal, then came more potent quinolones group specially second generation like pap medic acid and Norfloxacin. Now with the advent of the new more and more potent antibiotics it is not much of the problem any more, provided the antibiotics are given after proper cultures of the urine and antibiotic is given for long period.

Malignant tumours: Malignant tumours of the Kidney and bladder are curable in early stage but still are fatal in late stages. I used to do total cystectomy and anterior pelvic exoneration for locally advance bladder cancer. It was a formidable procedure and had no special benefit. So it was replaced by T.U.R.T. and chemotherapy. Lately a new chemotherapeutic drug Sunitinib maleate has been found very effective for carcinoma of Kidney even in advance stage.
As for as kidney transplantation is concerned, every new urologist calls himself a transplant surgeon even he has not assisted or seen a single transplant operation. Personally I believed that transplant surgery is a separate specialty. So there should be a separate unit reserved for this specialty. It should not only be reserved for kidneys but also for liver, heart and other organs transplantation. Transplantation is not only removing the viscera of the donor and anastamosing the three or more channels (artery, vain and ducts) in the recipient but also selecting the proper donor for the proper recipient, making the recipient body ready to accept the donated organ and keep it healthy. It involves a full team of pathologist, general physician, cardiologist nephrologists, general surgeon, transplant surgeon and excellent laboratory. Transplant surgeon should be a good vascular surgeon with experience in microsurgery.