UROLOGY

Urology

Urology is a branch of Surgery that handles all urinary problems in men, women and children and all reproductive problems in men, including:

  1. Erectile dysfunction
  2. Urinary or kidney stones
  3. Prostate problems like benign enlargement that comes with age, prostatitis, prostate cancer (which is the commonest cancer seen in Nigeria)
  4. Male infertility. In-Vitro Fertilization (IVF) does not treat infertility, it only bypasses the problem. As much as possible, couples would prefer to have the problem completely solved and have their children naturally. In about half of the cases, infertility in a couple is due to male problems, the commonest of which is low sperm count. The commonest cause of low sperm count is  varicocoeles. Varicocoeles are distended, tortuous veins of the pampiniform plexus, which drains blood from the testis. Because they are abnormal, blood flow is  sluggish, and testicular nutrition and sperm cell production are impaired. Varicocoeles are so easy to treat. IVF becomes a last resort to the few who do not respond appropriately to treatment. The most effective modality of treatment is surgical.
  5. Urogenital tumors e.g. cancer of the scrotum, bladder cancer, kidney cancer, cancer of the penis.
  6. Urinary tract infection (UTI) is one of the most common problems presenting to the Urology Clinic. Urinary Tract Infection is not sexually transmitted and must be differentiated from Sexually Transmitted Infection (STI), also called Sexually Transmitted Disease (STD) which is always acquired when there is sexual contact. UTI or STI is not caused by toilet infection as many women claim. But UTI can occur spontaneously, not due to any environmental or sexual exposure. In men, it is always due to a pathological problem in the urinary tract
  7. Sexually transmitted diseases
  8. Urinary leakages e.g. urinary incontinence, vesico-vaginal fistulas as in some women after childbirth
  9. Congenital defects of the urinary and reproductive tracts as seen in hermaphrodites, hypospadias, and epispadias. Some of these children look like male children externally but they are female internally. Some look like females externally but they are actually male children. It is important to determine the sex of the baby before a name is given. Sometimes we wait for the genital organs to grow a little more before we do reconstructive surgery at about 2 years of age. Appropriate surgery is done for the child to look like a normal male or female.
  10. Congenital hernias
  11. Urogenital trauma e.g. kidney injury, ruptured bladder, urethral injury.
  12. Kidney Infection
  13. Penile Curvature
  14. Genital Injury
  15. Prostate Inflammation
  16. Haematuria
  17. Retention of Urine, a condition where the urinary bladder can no longer empty completely
  18. Cystitis, which could be infective or not due to bladder infection
  19. Bedwetting
  20. Vesico-ureteric reflux
  21. Urinary Obstruction or any disturbance of the normal flow of urine from the kidney to the outside of the body, often caused by urethral stricture, ureteric stricture or stenosis; ureterocoeles, stone (also called calculus, urolith, urolithiasis). Calculi can occur in any part of the urinary tract and tend to cause a lot of pain.
Kelina Hospital Theatre
Our patients go home the same day or next after surgery
Kidney stones surgery active session
PCNL Surgery active session

Holmium Laser Enucleation of the Prostate (HoLEP)

In the entire West Africa Sub-region, it was Kelina Hospital that started Holmium Laser Enucleation of the Prostate (HoLEP). HoLEP is the most advanced form of prostate surgery. Laser removes the prostate with the least bleeding compared to all other methods. Patients can go home the same day or next day after their surgery.

Transurethral Resection of the Prostate (TURP) is recommended only for prostates less than 80g, according to the European Association of Urology. For prostates bigger than 80g, the recommendations on the current guidelines is that TURP should not be done; only HoLEP should be done. We have four lasers in all, three of which are suitable for HoLEP.

HoLEP has advantage over all other methods of prostate surgery in the following sense:

  1. It can take out prostates of any size, compared to TURP.
  2. There is minimal blood loss compared to TURP and open surgery.
  3. There is no external wound compared to open surgery.
  4. Patients spend very little time on admission, compared to TURP and open surgery. Patients can go home same day or next day after surgery.
  5. Patients can go back to work a day after discharge.
  6. Catheterization time after surgery is lower than with TURP or open surgery. Catheter causes infection. So the shorter it stays, the better.

We have performed 200 HoLEP procedures between October 2018 and November 2022 and all of them were carried out successfully. Typically, patients leave the hospital within 24 hours of surgery. It is possible that Kelina Hospital does more prostate surgeries than any other hospital in Nigeria today.

Experience counts!

Lithotripsy

Lithotripsy is a process by which kidney stones or stones formed naturally in any part of the urinary tract can be pulverized into powder, and the particles flushed out same day or through urine without the need for open surgical operation. Holmium laser, also called Ho:YAG laser combines the qualities of carbon dioxide and Nd:YAG laser in providing cutting and coagulation in a single device. It is capable of breaking up any type of stone in the urinary tract. We have the following methods of lithotripsy:

  • Holmium Laser
  • Ultrasonic Lithotripsy
  • Pneumatic Lithotripsy
  • Combined ultrasonic and Pneumatic Lithotripsy (the Swiss Lithoclast Master)

Kelina is the only hospital in Nigeria with the Swiss Lithoclast Master at the moment. We have two. The method selected for lithotripsy depends on type of stone and location.

Active surgical session in Kelina Hospital. Holmium laser being used to pulverize kidney stones in a process called Lithotripsy. The stones are then flushed or picked. Most patients go home the same day or next.

Ultrasonic Lithotripsy

Ultrasonic lithotripsy is most useful for Percutaneous Nephrolithotomy (PCNL). The stones suitable for PCNL are usually very large, above 2cm in diameter, and equipment dissipating minimal energy like the Ultrasonic lithotripsy is most useful for Percutaneous Nephrolithotomy (PCNL).

These kidney stones were removed in Kelina Hospital by Ultrasonic Lithotripsy

Pneumatic Lithotripsy

This can be used for stones in the urinary tract where semi-rigid rather than flexible scopes can reach. We have two pneumatic lithotripsy machines.

These kidney stones were removed in Kelina Hospital by Pneumatic Lithotripsy

Swiss Lithoclast Master

This is a beautiful machine made by the Dutch Company Electrosurgical Medical Systems, EMS. It combines both ultrasonic and pneumatic energy for lithotripsy. The Swiss Lithoclast Master is the most powerful machine in the world for lithotripsy, and can take out very huge stones in a few minutes. Kelina is the only hospital in Nigeria to have the Swiss Lithoclast Master. We have two, one in Abuja and one in Lagos.

These kidney stones were removed using the Swiss Lithoclast Master here in Kelina Hospital. The procedure lasted only about one hour.

Percutaneous Nephrolithotomy (PCNL)

The first PCNL in Nigeria was done here in Kelina Hospital. This is used for very huge stones in the kidney. Some of them are called Staghorn calculi. The staghorn calculus requires the Swiss Lithoclast Master to take it out. When the stones are so big, breaking them up into powder without picking up the particles is fraught with complications and delayed or failed passage (when you pour sand into a funnel, it may not necessarily pass).

A direct straight line small puncture gaining access to the kidney using PCNL will afford the opportunity to take out the stone directly. Ultrasonic lithotripter can be used to break the stone up into manageable pieces, and the pieces could be picked up one at a time or flushed out through the nephroscope, which is a part of the equipment used for this procedure. Kelina Hospital has two different types of nephroscopes for different types of stones (the standard 26F, the Dresden Nephroscope and Miniperc).

These stones were removed from the kidney of a widow, completely free of charge during our annual charity programme in 2011, in conjunction with Surgical Aid Foundation. This was the first PCNL to be done in Nigeria.

Miniperc

The Miniperc, as opposed to standard PCNL, gives a smaller puncture for PCNL. Morbidity is less, recovery is faster and patients can get discharged home earlier. Kelina Hospital was the first in Nigeria to acquire the Miniperc.

Picture of the first Miniperc procedure in this country; combined with laser lithotripsy for kidney stone.
Picture of the first Miniperc procedure in this country; combined with laser lithotripsy for kidney stone.
Picture of the first Miniperc procedure in this country; combined with laser lithotripsy for kidney stone.

Semi-Rigid Ureteroscope

This equipment is used to examine the entire urinary tract from external meatus through the bladder and ureter to the kidney. It is more suitable for certain procedures in the ureter and is more robust and durable than the flexible scope. Whenever possible, it is used instead of the flexible scope. However, it is more difficult to manipulate into certain positions within the kidney compared to the flexible  scope. For this reason, we acquired both. We have four systems for semi-rigid uretero-renoscopy. We do not use the same instruments for the general population as we use for those who test positive for HIV and Hepatitis.

Image of stone inside the ureter as seen during Intravenous Urography
Uretero-renoscopy

Cystoscopy

Kelina hospital has both rigid and flexible cystoscopes for day-case cystoscopy. When people have difficulty passing urine, or have any other lower urinary tract symptom, it is important to ascertain the cause.  Occasionally, people pass blood in urine. When people begin to pass urine frequently, it is easy for them to assume they have diabetes, infection or enlarged prostate gland. This is not always the case. In many cases, it is important to examine the urethra as well as the prostate and urinary bladder to be sure of the exact problem. Patients could also be fully awake and be able to visualize the entire process for themselves.

Common problems presenting with lower urinary tract symptoms include prostate enlargement either as a result of aging or cancer, bladder cancer and scarring or stricture in the urethra most commonly as a result of past infection but also due to injury to the urethra from past trauma or medical instrumentation. Stones in the urinary bladder could also obstruct urine flow.

Normal bladder and ureteric orifice

Transurethral Resection of the Prostate (TURP)

Kelina was the first hospital in Nigeria to acquire equipment for bipolar Transurethral Resection of the Prostate (TURP). Bipolar TURP is superior to monopolar, because ordinary drip (normal saline) can be used for irrigation or flushing out the pieces of  prostate tissue resected. Thus, if a large amount of the saline is absorbed, it does not pose any problem to the patient because it can easily be excreted with administration of a simple diuretic injection. Monopolar technology utilizes hypotonic solutions like glycine or dextrose water or even tap water for irrigation and patients who absorb a large amount of this solution can easily develop TURP syndrome, along with multiple complications. With our own technology, we have been able to resect prostate glands bigger than 200g. We have also been able to successfully carry out TURP on very ill patients and even patients with heart failure. The equipment used for TURP can also be used for transurethral incision of the prostate or bladder neck (TUIP), as well as Transurethral Vaporization of the Prostate (TUVP).

Enlarged Prostate. The median lobe is in the foreground. Urethra is obstructed
The two lateral lobes of the prostate are meeting in the midline. Urine cannot pass easily
The two lateral lobes of the prostate are meeting in the midline. Urine cannot pass easily

Uroflowmetry and Urodynamic Studies

This equipment is used to record changes in the bladder and bladder neck that affect urination. The flow of urine can also be measured vis-à-vis the behaviour of the bladder to help us determine if the problem with urination is from the bladder, bladder neck or nerves supplying the bladder.

This prostate gland was removed in Kelina Hospital in 2009. It was probably the biggest prostate that was ever removed in this country. It weighed nearly 1kg.
Normal Uroflowmetry tracing. Note that the tracing touches the 25ml/s line.
Uroflowmetry tracing in a patient with Bladder Outlet Obstruction (Prostate or Stricture). This type of patient needs urgent surgery.

Flexible Uretero-Renoscope

Kelina Hospital has multiple HD uretero-renoscopes from different manufacturers. With this equipment, the entire urinary tract can be examined up to the kidney. Any single pathology or problem in the entire tract can be accessed, visualized, assessed or sampled. Lasers can be coupled with this equipment for treatment of many of these conditions. Patients often go home the same day and return to work a day later with no external wound and with their problems treated.

Active session of flexible uretero-renoscopy and laser lithotripsy in Kelina Hospital.

Bladder Cancers

Bladder cancers can sometimes be removed completely using endoscopic equipment, without any external wound, a process called Transurethral Resection of Bladder Tumours (TURBT), similar to TURP. The patient must return from time to time for re-examination to be sure there is no recurrent
growth.

Bladder cancer growing inside the bladder, like a flower. It is being removed here in Kelina Hospital (TURBT). Patient’s first problem was passage of bloody urine and pain.

Valvotome

This is used for resection of Posterior Urethral Valves in children. Some male children are born with these valves right from their mothers’ wombs. The valves disturb urination. The entire urinary tract often gets distended with urine, and without treatment, the children end up with kidney failure. At
the moment, we do both optical and laser valvotomy.

Urethral Strictures

Occasionally, people have scars in their urinary tract as a result of past irritation, inflammation or infection. These scars can become so strong that they block the urethra and it becomes impossible to pass urine. The scars can be removed at open surgical operation or, in selected cases, divided using a process called Optical Urethrotomy or Visual Internal Urethrotomy (VIU). The operation leaves the patient with no external wound and he could return home much earlier than following open surgical operation.

Urethral strictures on Retrograde Urethrocystography RUCG
Urethral strictures on Retrograde Urethrocystography RUCG
Urethroscopy for same patient
Urethroscopy for normal urethra