There has been never a doubt in my mind that if there is any place for day care surgery, urology must be one of the few branches ideally suited for it. The concept was brought to fruition by my starting a purely day care urological clinic 7 years ago. A clinic that opens at 8.30 am and closes by 5.30 pm. About 700 sq feet area with 70 to 80 cases being done per month. That is efficiency indeed. And 7 years down the line, I have no regrets whatsoever.
Urology is suitable for daycare for various reasons. The advent of lithotripsy and endourology with contact lithotripsy has made stone treatment ideal for day care. Endoscopes have become slimmer and slimmer – the current rigid ureteroscope available in India is 6.4 F (2.1 mm in diameter). The optics is brilliant. Availability of endocamera gives great comfort and makes treatment and learning easy.
Also, urology has a number of smaller procedures eminently suited to the concept. Ninety nine per cent of the times, there is a degree of predictability in the surgery. It is very unlike abdominal surgery with so many ifs and buts and fortunately, the “Pandora Box” is literally non existent in usual urological surgery. Yes, you need the complete setup, no compromises, but once you have all the equipment in place, a lot of urology could be done easily and safely in day care.
Advances in anaesthesia have also helped. Short acting anaesthetics such as propofol and fentanyl, availability of very fine spinal needles (any case under spinal anaesthesia is done first case in the morning), and the ease and comfort of epidural anaesthesia makes the surgery safe.
Some cases are relatively major and need to be done early. The major cases include ureterorenoscopy for large upper third ureteric and renal calculi. These procedures take about 1 hour and may need regional anaesthesia; they also need longer recovery periods. Again, lithotripsies, though relatively minor, many times need to be done early in the morning as patients usually have their bowels prepared for better visualization. I have not liked to do PCNLs on day care, although we have done percutaneous nephrostomies in dilated systems. Open surgical instruments must be available for any emergencies.
Another endoscopic procedure which we do not do on day care is TUR –P and TUR – BT. These have potential major complications and should be absolute contraindications for Day Care. All other endoscopic procedures are fair game. Cystoscopy, biopsies, D-J Stenting, Visual internal Urethrotomy, cystolithotripsy, endoscopic meatotomy, Sting procedure (submucosal Teflon/deflux injection for reflux), balloon dilatation of ureteric strictures and Pelvi-Ureteric Junction Obstruction, Hydrodistension of Bladder, Injection of Botox, Paediatric Cystoscopies with fulguration of post urethral valves; all these procedures can be done on day care basis. Patients are sometimes sent home with a Foley’s catheter, to be removed conveniently later.
A lot of minor surgical procedures in urology are also comfortably performed. These include circumcision, vasectomy, testicular biopsy, meatotomy/plasty. We have also enjoyed performing A.V fistulae on day care. Many other minor procedures such as urethral dilatation, intravesical BCG Instillation, trocar suprapubic cystostomy, etc, are done on Day Care.
Other procedures like varicocoele, hypospadia, etc, may be possible on day care; I usually do not recommend these on day care basis, as different patients have different threshold to pain and may be uncomfortable having to go home immediately after the surgery.
Safety Precautions: It is necessary to remember that mishaps can happen to even the best intentioned, the most cautious and the most experienced. Insure and be secure. No surgery must be taken too lightly; backup systems must be in place and you should be prepared for every emergency. Medico legally, the outcome is not the most important; it is important to have emergency equipment in hand, and to use them in time. Never be shy of calling for help and/or shifting the patient to a better equipped hospital. Also, you must use your judgement (despite pressures from various quarters) to decide which case can and may be done in your centre.
Mediclaim: Fortunately, more and more insurance companies have realized the benefit of day care surgery. Unfortunately though, as far a urology is concerned, only lithotripsy may be done on day care. This is covered under clause 2.3 of the insurance laws. Efforts must be made to allow other procedures also on day care.
The future: TVT – Sling surgery for stress urinary incontinence is now accepted abroad on day care. Centres in the west have already started doing prostate laser resection on day care basis. The advent of KTP laser has made this possible. Many centres in the west do major laparoscopic surgery (with or without robotics) on Day Care. The future is bright – indeed, the future is DAY CARE.
LONG-TERM EFFECT OF DOXAZOSIN, FINASTERIDE, OR BOTH ON THE CLINICAL PROGRESSION OF BENIGN PROSTATIC HYPERPLASIA
In this long-term trial, the combination of an alpha-blocker (doxazosin) and a 5a-reductase inhibitor (finasteride) was superior to either drug alone in retarding the clinical progression of benign prostatic hyperplasia.
N Engl J Med, 2003; 349 : 2377. |
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