Endourology at district place

by Dr Prashant Mulawkar, Akola

How it went?

I was born and brought up in a very small nondescript village in Vidarbha. It was in 1992, when I was doing my MS general surgery at GMC Nagpur that one of my colleague Dr. Ajay Oswal, presented a seminar on recent advances on management of kidney stones in India. The talk included some discussion about percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (SWL). Of course, at that time of my career, such treatments appeared unbelievable and a part of the fantasy world.  I even thought that Ajay must be bluffing (which he never used to do) and telling us something which was just experimental in the western world. I even argued with him and contradicted him. To my surprise he showed me an article in ‘Recent advances in Surgery’ edited by Dr. Roshan Lall Gupta by a person called Dr. Percy Jal Chibber. Never had an idea that someday I would be able to work with the very same man.

I joined St George’s and JJ hospital in 1993. JJ hospital was the first public hospital where PCNL was started. So, all four of us (Dr. Pankaj Maheshwari, Dr. Akhilesh Chandra, Dr. Nagesh Kamat and myself) got to see and do PCNLs and ureteroscopy fairly early in our training. Both the units were well equipped to do upper tract endoscopic surgeries. I was enjoying my JJ days and had plans to work there forever. But Dr. Chibber had some other suggestions for me. He asked me settle at Akola and start with a complete endourology unit there. His words were, “Go to your own people and serve them. You are a urologist trained in the best center. Your people should be getting PCNLs and not pyelolithotomies.” The idea was good on paper and in mind but not palatable as the population of Akola that time was just 3.2 lakh. I discussed the economics with Nagesh, Pankaj and Manish (Bansal) and a plan to start lower tract work first and then go on building equipment bank was devised. This idea was blatantly refuted by Dr. Chibber. Minimum basic (upper and lower tract) set those days costed Rs 14 Lakh without camera. I started with an OPD at Akola and would travel from one place to other carrying equipment in an auto-rickshaw as I could not afford to buy a car.  Cases needing C arm were done in Orthopedician’s hospital. The ortho OT tables were not useful, so a wooden extension attached to the foot end of hydraulic table was the most commonly used alternative. Internet was obviously not available. I was the only urologist in Akola. For taking second opinion, I used to send stone outlinogram of plain film and IVU to Dr Oswal (most of the times) and Dr. Chibber (occasionally) by fax. The calyces would be numbered 1,2,3 and opinion about best calyx for entry was discussed. Dr Oswal used to come to Akola (from Aurangabad) by bus and we used to operate complex PCNL cases together. 

Building up the Equipment bank

The first ureteroscope I acquired was 8.5/11.5Fr and the Nephroscope 27Fr required a 30Fr Amplatz sheath. After just a few cases I realized that I was not made for roaming practice. I decided to keep all equipment in one small nursing home where I used to do all lower tract surgeries and PCNL and ureteroscopy at orthopedician’s hospital. The ultrasonic lithotripter was unreliable so had to buy pneumatic one. By this time Indian pneumatic lithotripters were easily available. Another hurdle was non-availability of C-arm. The loan taken for the endoscope set was still going on. But there was no way we could live without C-arm. Those days some of my friends used to do ureteroscopies and stenting without C-arm. But I was extremely uncomfortable doing these procedures without C arm. Another loan was taken and dealer was persuaded to accept part payment. 

We presented our first experience of PCNL monotherapy in staghorn calculi in an Asian congress. The moderator asked, “Do you have access to angiography? He suggested I should not be doing these procedures as angiography was not available.” Of course building an angiography suite was not in my hands. For me the 2004 Kukraja & Desai [1] paper was an eye opener. I thought I should buy a slender nephroscope, so another investment. By that time some manufacturers had started manufacturing slender nephroscopes. The 8.5/11.5 ureteroscope was fairly bulky. Soon we bought two ureteroscopes 8Fr and 6Fr. Stone migration during pneumatic lithotripsy was an issue. That necessitated buying a low power holmium laser. This was one of the first few low power lasers bought in tier 3 cities. The low power laser had some limitations so son we had to upgrade it to a 100 watt holmium laser. This was the first installation of high-power laser in a tier III city in India.

Today we have a fully equipped endourology OR with two HD Image 1S cameras, seven nephroscopes (one 27Fr, One 24Fr, Two 17/22Fr, One 12Fr, one 4.5 and one flexible); eight ureteroscopes (one 8.5Fr, two 8Fr, two 7Fr, One 6Fr, one 4.5Fr and one flexible), two laser machines (one 100 watt Holmium and one 35 watt Thulium fiber). Almost all sets are sterilized by ETO. In addition, we also have a flat panel detector (FPD) C arm. This happens to be the first installation of FPD in a urology unit in India. 

Building up Radiology

The IVPs done those days were not as per my requirements and satisfaction. I used to go to radiology clinics and shoot the IVPs personally. Most of my radiology colleagues quickly started following a standard protocol. As sending patients for check X ray KUB after the procedure was a hassle we bought a 300 mA X ray machine. I tried to learn ultrasound guided puncture, so bought a sonography machine. But I was more comfortable with fluoroscopic puncture. Today we have two ultrasound machines with colour doppler and one computerized X ray unit. Things were changing. IVPs were not the norm. CT was the necessary investigation so I invested in a CT scan machine. This CT is a multi-partner project. The fun here is we get all DICOM files immediately. We do all our 3D reconstructions, HU measurements, stone volume measurement sitting in my clinic. We have our own DICOM server where all radiology data is kept achieved.

Record keeping

It was Dr. Chibber who ignited the love for computers in my mind. The first PC I bought was in 1997. Those days a desktop PC would cost Rs 65000. But I started keeping all the important data on PC. Today we have all the operations for last twenty years recorded on various media. This has helped me in writing few papers. Although we are sitting on a heap of data, we write just about pinhead size of it. I have been trying to improve on this aspect, but the progress in this regard is pretty slow. 

Manpower

Getting trained hands is not possible at district place. We have to train our boys and they develop interest soon. They can predict which scope would be required or which calyx would be selected for access. Managing the huge workload is tiring but very satisfying if you have the passion to do the things. I can say with pride that we have seen almost all the conditions described in Campbell’s urology. Today we are a team of two urologists working together. 

So is advanced endourology practice possible at district place?

Answer is  “Yes”

What one needs is:

  • Desire to do it
  • Develop department by gradually investing as required
  • Develop manpower to help you
  • Develop other colleagues (pathologists, radiologists) in your city to match your skills and requirements
  • Develop a team so you can enjoy your work

Finally such efforts help your own people who cannot afford to go to metro’s for treatment and this is a very satisfying journey. 

References

Kukreja R, Desai M, Patel S, Bapat S, Desai M. First prize: factors affecting blood loss during percutaneous nephrolithotomy: Prospective Study. Journal of endourology. 2004 Oct 1;18(8):715-22.

Endourology at district place
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