Clinical Procedures

Robotic Surgery

Robotic surgery, or robot-assisted surgery, allows urologists to perform various complex procedures with higher precision, flexibility and control than is possible with conventional open techniques.

The most widely used clinical robotic surgical system includes a surgeon controlled camera arm and 2-3 mechanical arms with attached surgical instruments. The chief operating surgeon controls the arms, while seated at a computer console near the operating table. This console gives the surgeon a high-definition, magnified, 3-D view of the surgical site. An additional surgeon sits by the patient end to enable smooth progress of the surgery. Robotic surgeries have multiple advantages over conventional open surgeries, which include – lesser pain and blood loss, quicker recovery, smaller and less noticeable scars, and generally fewer complications (such as surgical site infection and incisional hernias among others).

Robotic Setup

Almost all oncological as well as numerous complex reconstructive surgeries in urology can be performed robotically with clinically better outcomes as opposed to conventional surgery.

We have access to the latest generation Da Vinci Xi robotic system that enables us to perform surgeries like Radical cystectomy, Radical prostatectomy, Radical nephrectomy, Partial nephrectomy, Pyeloplasty and many more with ease.

Surgeon Console
Patient Cart with Assistant Surgeon
Robotic Ports
Cosmetic Result

Laparoscopy for all Urological Conditions

Laparoscopy, also known as keyhole surgery, refers to a minimally invasive surgical procedure; which is performed using a laparoscope -a small fibreoptic instrument with a connected camera and lens.

This small telescope is equipped with a built-in magnification mechanism. During the surgery, different types of surgical instruments are inserted through small incisions made in the skin. Laparoscopy offers several diagnostic and therapeutic benefits, just like traditional open surgery. It also has significantly reduced postoperative pain, ensures shorter hospitalisation, speedier recovery, and far better cosmetic results.

Today, rapid advancements in the field of medicine and technology have enabled doctors and physicians to perform laparoscopic surgeries for the treatment of different types of urological conditions.

Laparoscopy for all Urological Conditions

Some of the most commonly performed laparoscopic surgeries for urological conditions include:

Laparoscopic Simple or Radical Nephrectomy: A simple Nephrectomy refers to the removal of the affected kidney. A radical nephrectomy, on the other hand, is a procedure that involves the removal of kidney along with lymph nodes and sometimes, the adrenal gland. Laparoscopic nephrectomy is recommended for patients with kidney cancer, symptomatic hydronephrosis, chronic infection, polycystic kidney disease, shrunken blocked kidney, hypertension or renal calculus.

Laparoscopic Donor Nephrectomy: Laparoscopic donor nephrectomy is a procedure that involves the removal of a kidney for the purpose of donating it to another patient. Some dangerous donor complications that might occur during this procedure include – injury to the renal vessel or bowel, hematoma, and incisional hernias, which are essentially same as those of a conventional, open surgery.

Laparoscopic Nephroureterectomy: It is a surgical procedure in which the kidney and the ureter are removed. It is mainly used to treat patients suffering from transitional cell carcinoma of the ureter or kidney. Risks include – infection, loss of blood and injury to the surrounding tissue and organs such as bowel, lung, vascular structures, spleen, liver, pancreas and gallbladder.

Laparoscopic Partial Nephrectomy: This is a surgical procedure, used to remove the damaged part of a kidney containing a tumour.

Laparoscopic partial nephrectomy is usually performed in patients suffering from a solid renal mass in a solitary kidney or compromised contralateral kidney, bilateral renal tumours, and those who have a normal contralateral kidney with localized small renal tumours.

Various risks and complications of this procedure include – infection, loss of blood, hernias at incision sites, urine leakage, and sometimes, injury to the surrounding the tissue and organs like any other surgery. However, delayed bleeding is a rare, but serious complication that requires urgent medical attention and intervention.

Laparoscopic Pyeloplasty: Laparoscopic Pyeloplasty is a surgical procedure that helps relieve the obstruction between the ureter and the kidney located in the ureteropelvic junction. Associated risks include infection, loss of blood, failure of surgery and injury to the surrounding tissue and organs.

Laparoscopic Radical Prostatectomy:  It is a surgical procedure involving removal of the prostate gland and some surrounding tissue . This procedure is highly effective in the treatment of localised prostate cancer or that, which has not spread beyond the prostate gland.

Potential risks include – infection, bleeding, urinary incontinence, erection problems, uretherovesical anastomotic leakage, hernias at incision sites, and injury to the surrounding tissue and organs.

Laparoscopic Radical Cystectomy: It is a surgical procedure that involves the removal of the urinary bladder, and is usually recommended for patients with muscle-invasive bladder cancer. Possible risks include blood vessel injury, bowel leak, urine leak, chest complications, prolonged hospitalization and re-exploration among others.

Laparoscopic Surgery for Kidney Cancer

Kidney cancer can be treated with minimally invasive techniques such as laparoscopic partial nephrectomy and laparoscopic radical nephrectomy. During these surgical procedures, doctors may either remove the tumour and a small portion of healthy tissue, or the whole kidney. Following laparoscopic partial nephrectomy, patients can resume their normal activities in less than half the time it takes to completely recover from an open surgery.

Laparoscopic Surgery for Kidney Cancer

Laparoscopic Surgery for Bladder Cancer

Patients suffering from advanced bladder cancer may need to remove either a part or their entire bladder through procedures like Partial and Radical cystectomy. The former is performed when cancer has spread to just a portion of the bladder wall, but the latter is needed, when the cancer has invaded the whole bladder. In this process, the entire bladder as well as nearby lymph nodes and organs are removed. A new structure known as a ‘neobladder’ that enables patients to store urine inside the body or in an external pouch is created. Cystectomies are performed using either a traditional or robotic laparoscope as the recovery is swift and smooth.

Laparoscopic Surgery for Prostate Cancer

Radical prostate surgery is performed using a laparoscopic surgical robotic unit called the da Vinci system. This innovative surgical system provides surgeons easy access to the prostate through a few minor incisions. Small surgical instruments also enable tissue manipulation with great precision, and prostate gland removal, while reducing harm to surrounding tissues. The da Vinci system also provides surgeons a considerably enhanced magnification of the surgical field, making it easier to view and avoid critical nerves that pass through the prostate. This in turn tremendously reduces the complications associated with urinary incompetence and impotence.

Reconstructive Urology

Reconstructive Urology is a specialised field in urology that focuses on restoring both – the structure and functions of the genitourinary tract. Conditions that can necessitate reconstructive surgery are – prostate procedures, trauma such as industrial accidents; straddle injuries, urethral strictures and sometimes, complicated childbirth involving tear in tissue.

Surgeons should have extensive expertise in performing complex reconstructive surgery on the kidney, ureter, bladder, urethra and male genitals. Common reconstructive surgery procedures include:

  • Urethral disruption injuries caused by a fractured pelvis
  • Recto-urinary fistulas following prostatectomy or pelvic surgery or after radiation therapy
  • Refractory male urethral strictures
  • Major bladder reconstruction
  • Major ureter reconstruction
  • Vesicovaginal or ureterovaginal fistulas after pelvic surgery
  • Male urinary incontinence
  • Peyronie’s disease

Endourology and Laser Treatment for Stone & BPH

Endourology is the specialised branch of urology that deals with the closed manipulation of the urinary tract. It comprises all urologic minimally invasive surgical procedures, and is generally performed with the help of small cameras and instruments inserted into the urinary tract. This facilitates prostate surgery, surgery of tumours of the urothelium, kidney stone surgery, and various urethral and ureteral procedures.

Endourology and ESWL for Stone Disease

Extracorporeal Shock Wave Lithotripsy (ESWL)

Extracorporeal Shock Wave Lithotripsy (ESWL) makes use of shock waves to disintegrate a kidney stone into small pieces so that they can travel easily via the urinary tract and pass out of the body.

The Procedure

  • In this procedure, the patient lies on a water-filled cushion, and the surgeon uses X-ray or ultrasound tests to accurately identify and locate the stone. High-energy sound waves are passed through the body, thus fragmenting the stone into small pieces, which enables them to pass through the urinary tract and out of the body easily.
  • The entire process takes only about an hour and is performed using local anaesthesia.
  • A stent may be placed in the ureter if you have a large stone, to allow small stone pieces to easily pass without causing ureter blockage

ESWL is generally an outpatient procedure. Following the treatment, stone fragments tend to pass in the urine for a few days, which could result in mild pain.

Kindey Stones and Uninary Tract

Why it is Done

ESWL is usually performed on those suffering from kidney stones that are causing pain or blockage of urine. Kidney stones that are between 4 mm and 2 cm in diameter are usually treated with ESWL. It also treats stones in the kidney or in the part of the ureter that is adjacent to the kidney.

However, ESWL is not recommended if the individual is:

  • Pregnant
  • Has a bleeding disorder
  • Has infection in the kidney or urinary tract
  • Has kidney cancer
  • Has abnormally structured kidneys or if there is problem in the functioning of the kidneys

Risks or Complications

  • Intense pain caused by the passage of fragments of stone
  • Blockage in urine flow
  • Infection in the urinary tract
  • Bleeding on the outside of the kidney

Retrograde Intrarenal Surgery (RIRS)

Retrograde Intrarenal Surgery (RIRS) is a surgical procedure performed within the kidney using a viewing tube known as a fiberoptic endoscope.

In this procedure, the endoscope is placed via the urethra into the bladder and then passed through the ureter into the part of the kidney wherein the urine gets collected. In this way, the endoscope is moved up to the urinary tract system to a specific position within the kidney.

RIRS is generally performed to remove a stone or a small tumour. The stone can be directly visualized through the endoscope, and then fragmented using an ultrasound probe, evaporated with the help of a laser probe or grabbed using small forceps. It is typically performed under general or spinal anaesthesia.

Retrograde Intrarenal Surgery (RIRS)

Advantages of RIRS

Some of the major advantages of RIRS over other surgeries include access to all parts of the kidney that have stones, less pain and bleeding following the surgery, and faster recovery.

RIRS is recommended for patients who are suffering from kidney stones or in certain cases such as narrowing of the kidney outlet or related strictures and tumours.

RIRS is mainly used for treating certain difficult conditions such as:

  • Previous treatment attempts that have completely failed
  • Large stones that cannot be removed using ESWL
  • Strictures or tumours
  • Stones in children
  • Patients suffering from bleeding disorders
  • Patients suffering from gross obesity
  • Patients with odd anatomy

Micro perc (Micro PCNL)

Standard percutaneous nephrolithotomy is an extremely effective procedure that helps remove renal calculi. However, it results in significant morbidity.

Mini-percutaneous nephrolithotomy, performed using a 15F or 16.5F ureteroscopy sheath, tremendously reduces the morbidity associated with standard percutaneous nephrolithotomy and simultaneously maintains the effectiveness of stone removal.

Micro perc (Micro PCNL)

Microperc’ (Micro PCNL) is a procedure performed using a 16-gauge needle.

One of the major disadvantages of Extracorporeal Shock Wave Lithotripsy (ESWL) is its unpredictable result. While the prominent limitation of Retrograde Intrarenal Surgery (RIRS) is high-cost, a limitation is its invasiveness and associated morbidity.

Reduction in the tract size helps reduce the invasiveness of the procedure and potential complications. In Microperc or Micro PCNL, the procedure is performed through a 4.85-Fr (16 gauge) tract. The underlying hypothesis of the ‘All-seeing needle’ is that if the initial tract is perfect, then the tract-related morbidity can be substantially reduced. The optical needle also helps eliminate any traversing viscera. Yet another advantage of microperc is that it is a single-step renal access procedure, which results in a shorter insertion. It thus provides a novel standard of obtaining renal access.

Micro perc (Micro PCNL)

Ureteroscopic Removal Of Stone (URS)

Urinary stones present in the ureter, particularly hard stones or those that cannot be treated with ESWL, can be treated using laser. URS is a procedure used to treat stones situated in the middle and lower ureter. This procedure is performed under general or spinal anaesthesia.

A ureteroscope, or a small fiberoptic instrument is inserted through the urethra and bladder into the ureter, which enables the urologist to directly visualise the stone present in the ureter.

While small stones are removed using a specialised stone basket, large ones are disintegrated using a laser or a similar device. A stent may be placed in the ureter for a few days following the treatment in order to facilitate healing and prevent blockage caused by inflammation or spasm. The stent is usually removed 8-14 days after surgery using flexible cystoscope as an outpatient procedure.

Percutaneous Nephrolithotripsy (PCNL)

Percutaneous Nephrolithotripsy (PCNL or PNL) refers to a minimally invasive endoscopic treatment that is used for removing staghorn stones, large kidney stones or multiple stones in the upper ureter.
In this procedure, a puncture is created in the skin through the kidney to the stone and a telescopic port is inserted, without any big incision required. A telescope known as a nephroscope is passed through this port into the kidney to disintegrate the stone and break it into pieces, to remove the debris from the stone. PCNL or PNL is performed under general anaesthesia and real-time X-ray control called fluoroscopy. The surgery may last for 1 or 2 hours.

Percutaneous Nephrolithotripsy (PCNL)

Prominent advantages of PNL or PCNL include:

  • Eliminating the large skin incision caused by pervious kidney surgery for stones
  • Removal of all fragments removed during surgery
  • Faster recovery and healing as compared to other procedures
  • Shorter hospital stay – 2 or 3 days

Percutaneous stone surgery may also be recommended in certain conditions where the ureter below one of the kidneys is obstructed, or in ureteropelvic junction obstructions.

Laser Surgery For BPH/Prostate Enlargement

Laser surgeries such as THULEP/HOLEP are used to relieve moderate to severe urinary symptoms caused by an enlarged prostate — a condition known as Benign Prostatic Hyperplasia (BPH).

During prostate laser surgery, the concerned doctor inserts a slender cystoscope through the tip of the penis into the tube that carries urine from the bladder (urethra). The prostate surrounds the urethra and if enlarged, restricts urine flow from the bladder. A laser passed through the scope delivers energy that shrinks or removes excessively enlarged prostate tissue.

Laser surgeries for BPH offer several advantages over conventional methods including – lesser bleeding, quicker recovery, shorter hospital stay and shorter duration of indwelling catheter. Laser surgery can be performed on patients who use blood thinning medications, without the need for stopping the latter.

For smaller prostates, the ablation of tissue is done, known as – THULAP (Thulium Laser Ablation Of Prostate). For larger prostates, anatomical enucleation is done, which is known as – THULEP (Thulium Laser Enucleation Of Prostate) or HoLEP (Holmium Laser Enucleation Of Prostate). A reoperation is hardly required, as compared to the conventional TURP technique, as almost the entire prostate gland is removed in laser surgery, which is its real USP.

Conventional TUR-P
Removed Prostate Tissue

Vascular Access for HD

One of the most important steps prior to starting Hemodialysis is preparing a vascular access, which refers to a particular site on the body from which the blood could be removed and returned. A vascular access is often prepared several weeks or months before the Hemodialysis commences. A prominent advantage of vascular access is that it enables easier and efficient removal and replacement of blood, and that too, with minimal complications. A standard Hemodialysis treatment involves the continual processing of around 200-500 ml of blood per minute over a 2-6 hour period, and is usually performed 2 or 3 times per week.

This process should always be prepared weeks or months prior to dialysis. This prompt preparation facilitates efficient removal and replacement of the blood with fewer risks or complications. A properly functioning vascular access should have these characteristics:

  • Perfectly safe and well tolerated
  • Involves less complications
  • Provides continuous access to circulation
  • Provides continuous flow of blood of around 200-500 mL per minute
  • Easy to place and easy to use
  • Fully acceptable to the patient
  • Painless and cosmetically acceptable

The three important types of vascular access for Hemodialysis are – an Arteriovenous (AV) fistula, an AV graft, and a Venous catheter.

Conventional Arteriovenous Fistula (AV) Fistula

An Arteriovenous fistula (AV) fistula is greatly useful as it increases the strength of the vein and facilitates easy access to the blood system. It is regarded as the best long-term vascular access for Hemodialysis as it ensures sufficient blood flow, lasts for a longer period of time, and has fewer complications than other access types.

An AV fistula requires cautious advance planning as a fistula often takes some time after surgery to develop in certain cases, usually 4-6 weeks.  It is created by connecting an artery directly to a vein, quite often in the forearm, to enhance the flow of blood into the vein. In due course, the vein grows larger and thicker, which in turn makes repeated needle insertions for the treatment easier. The surgery is performed using a local anaesthetic.

Once referred by your nephrologist for creation of AV fistula, you will be thoroughly assessed by our expert team and then a suitable site for fistula creation will be decided basis clinical findings and Doppler reports.

Arteriovenous Graft

If there are small veins that won’t develop into a fistula, a vascular access that connects an artery to a vein is created with the help of a graft or a synthetic tube, implanted under the skin in your arm. This graft acts as an artificial vein that can be repeatedly used for the placement of needle and blood access during the process of Hemodialysis. A graft could be used soon after placement.

Vein Transpositions

For patients who require Hemodialysis, a properly functioning vascular access is crucial for achieving optimal quality of life. If a suitable cephalic vein at the forearm and upper arm cannot be found, an arteriovenous fistula (AVF) is made using a prosthetic graft or a transposed basilic vein. The latter is completely protected from venipuncture owing to its deep position in the subfascial plane.

Basilic vein transposition (BVT) was first performed in 1976 and is considered a viable option for secondary or tertiary vascular access. Fistulas made with a transposed basilic vein have been found to be the most reliable secondary vascular access procedures for chronic Hemodialysis.

Conventional BVT

In Conventional Basilic vein transposition (BVT), a long incision is made over the medial aspect of the arm. The basilic vein is dissected up to the axillary vein and transposed into the subcutaneous tissue using multiple small incisions, followed by End to side basilic vein brachial artery anastmosis.

Conventional BVT

Transposition of Basilica Vein with Minimal Incision

In this process, performed under local or regional anaesthesia, a transverse skin incision is made on the antecubital area to identify a basilic vein and brachial artery. Following this, three or four longitudinal skin incisions are made along the basilic vein, which is is then pulled out toward the axillary region. With the help of a tunneler, tunneling is performed under the skin and the full length of the basilic vein is transpositioned towards the lateral side of the upper arm. End to side basilic vein brachial artery anastmosis then conducted, with a small or minimal incision applied to basilic vein transposition to lessen the pain and make patients more comfortable.

Single Port Surgery

As the name indicates, single port surgery is performed through a single entry point, and is a minimally invasive laparoscopic one. The incision is made on the belly button (navel) of the patient. This surgery requires an incision of 20 mm and is more beneficial when compared to traditional laparoscopic methods. It causes less pain, blood loss and ensures faster recovery during the post-operative phase. The traditional laparoscopic method requires more than five incisions to insert the instruments needed for the surgery, whereas in single port surgery, four instruments can be used from the same port.
In certain cases, a candidate for laparoscopic surgery might also be eligible for a single port one.

During the procedure, the doctor will give anaesthesia to the patient, and follow it up with making an incision. The surgery is performed using specialised instruments, with the surgeon using up to three laparoscopic devices through the small incision using the flexible port. This activity requires training and high skill, and offers the advantage of little or no scarring. It doesn’t have many complications or risks associated with traditional surgeries.

Even though the surgery is beneficial, it has a few complications. One is that it is quite challenging. The freedom to use multiple instruments is restricted as there is only one entry point for all instruments, and only specialised ones can overcome the issue.

Single port approach can be used in various procedures such as:

  • Living kidney donation
  • Removal of a kidney
  • Freezing of cancerous tissue
  • Removal of prostate
  • Bladder removal
  • Pelvic organ prolapse treatment for women
  • Reconstruction of the urinary tract
  • Enlargement of the veins within the scrotum

Single port surgery may also share complications of other surgeries such as injuries to organs, bleeding, infection, intestinal adhesion, incisional hernia and scarring.