Top healthcare experts discuss the roadblocks and latest advancements in urology, urology cancer and more. Dr Anup Kumar, HoD of urology, Safdarjung Hospital, Dr Anand Kumar, head of urology and kidney transplant division, Max Hospital, Dr Rajiv Sood, dean of PGIMER, RML Hospital and chairman of Indian School of Urology, and Dr Amlesh Seth, HoD of urology at AIIMs, put forth their views. Excerpts:
Q. What are the challenges involved in kidney transplant?
Dr Anand Kumar: Kidney transplant involves two people, one person who is going to get the kidney and the other who will donate it. This is a unique situation in the medical field as it is the only operation in which a healthy person is undergoing an operation to give one of the organs or part of the organ to someone else to live. Somebody who has just died has agreed to donate his organ then his organ can also be given to others. It is a big challenge. Nowadays there are nuclear families, suppose someone has kidney disease, previously in the family there used to be at least three to four children but now usually there are only two children. If they are not matching there is a problem and if one has gone outside the country or some other thing then there is a problem in finding a particular donor for kidney transplantation. Apart from this, it is also a financially and emotionally draining situation. Your treatment is expensive, it goes throughout life and the initial preparation is also required as the patient undergoes dialysis and a lot of tests. We have to see if the patient is fit or not to undergo the transplant. His donor also has to go through a lot of tests. All these issues are there and then we go for the transplantation. Sometimes no family member is fit to donate even if they want to. Only a healthy person can donate, suppose the donor has got some liver disease, both his kidneys are not good, he has diabetes, has major pressure issues or heart disease so even if he is willing to donate and wants to save the other person, he still can’t do that. We can’t risk his life while taking out his kidney in donation as our job is to make sure that the person who is donating should remain healthy, he should not suffer and the one who got the kidney should also do well.
Q. How much risk is involved in a kidney transplant?
Dr Anand Kumar: Kidney transplant nowadays has become a very routine procedure. Firstly, we will take the kidney donation, it is done electroscopically. The patient is admitted for three to four days. The procedure usually takes one to two hours, the next day the patient needs only a small procedure to take the kidney out, the next step is walking around, moving around, and on the third-fourth day, the patient is discharged. Within two to three weeks, he is fit and fine after which he doesn’t need to take any medication or precaution. He can do anything except two things, he cannot join the army and police force. Besides that, he can go hiking, cycling, and produce children so the donor has no risk. The operation has become very safe but in one out of 3000 cases there can be some complication.
Q. Do you think we need awareness as people still feel that they should not donate a kidney, especially family members and there is some hesitation?
Dr Anand Kumar: Yes, it needs awareness and we salute those who donate their kidney, it is not an easy decision. If I ask somebody to give Rs 100 he would think a few times before giving it. If I ask somebody to donate his blood, it would not be a problem as when you give the blood nothing happens, within a few hours your blood is replaced. Still, people are hesitating to donate. Asking somebody to undergo some major operation to donate their kidney is not at all that simple but still, people do it. It takes a lot of courage and self-determination to donate and help somebody. They are doing a very altruistic act to save somebody’s life; it is not an easy decision and takes time. We counsel them, give them literature to read and build their confidence. A lot of people come forward so I salute them that they have done a great job, and saved somebody’s life. It needs awareness that donation is simple and safe, there is no disfiguration of the abdomen and very soon you will be back to your work and can do anything. Another thing that needs a lot of awareness is cadaver donation. Many people are dying because of roadside accidents, brain haemorrhage, a clot in the brain, and sudden cardiac death so when they are in the hospital their family agrees to donate their organs. One person can save many people’s lives, you can donate eyes, liver, lungs, heart, kidneys, pancreases, small bowel, cartilage and other organs. One person can save seven lives when the family allows it. There is the system, law, many foundations, and NOTO (National Organ Transplant Organisation), so there’s nothing to fear about. The family just has to give consent.
Q. What is urology cancer? Does a urologist treat cancer?
Dr Anup Kumar: Yes, urology cancer is treated by a urologist, we call them urooncologist. It is a separate speciality these days and that includes cancer, soft kidney, and bladder, etc. All these cancers have various presentations, various stages and a lot of advances have taken place in the field of urology. Earlier it used to be open surgeries for all cancers. Then there are laparoscopic surgeries, minimally invasive surgeries, but then laparoscopic surgeries had some disadvantages and limitations especially in certain challenging cases. Then came the era of robotics and this era came in the last 20 years, we are seeing its benefits in terms of least mobility to the patients and decrease in mortality. Patients don’t have long insurgents which we give in the open surgery so there is less pain, less blood loss, lesser need for the blood transfusion and the patient recovers faster. In terms of the outcome, we recover cancer totally, not leaving cancer behind. That is known as R0 resection efficacy is also increased, enhanced and is equivalent to open surgery. Functional outcomes and quantity of life outcomes are very important in today’s era. The patients are aware of these things and demand a good quality of life which we can give them. Talking about radical prostatectomy, earlier the patient feared that they would leak the urine continuously after surgery and had many other fears. Nowadays with the robotic approach, we can not only give them excellent continence and many of the patients are immediately continent after surgery and almost 80-90% will become continent in three months which is a very good number. We can also preserve the nerves which give normal life after surgery.
Q. How Artificial intelligence (AI) is useful in urology?
Dr Anup Kumar: AI is a big field that is going to be there in the robotic field. Right now, we are not using AI, but we have the robots which are coming, these robots don’t have haptic feedback, i.e. no tactile sensation which we have in open or lab. In AI we are going to have haptic feedback again and that will improve the outcome of the surgery. AI is the future of all these technologies, especially robotics.
Q. What are the latest developments in urology?
Dr Amlesh Seth: There are so many developments that it is very difficult to talk about one or two. Dr Anup has already talked about robotics and AI. In urological cancer, gene therapy is coming up and targeted therapy has already been there and there are multi-mortality treatments for urological cancer which becomes more and more streamlined. The cure rates for testicular cancer is 99% and good longevity is provided in patients with prostate cancer, kidney cancer, and bladder cancer. In bladder cancer, a new bladder formation has been going on and in about two to three decades, if the urinary bladder is taken out then the new bladder can be formed from the intestine. The patients avoid it almost as if the patient has an inactive bladder. People fear the bladder being removed.
Q. How Covid-19 has affected urology?
Dr Rajiv Sood: In urology we have all kinds of exposures to the health workers which are there in any other discipline also but the special thing is that in urology we are having a lot of diseases which are very common like UTI, cancer, the kidney stones, or any disease ureteric disease for the elderly where the comorbidities are also there. We have elderly patients, a patient profile that should not be exposed to the Covid pandemic and also they are pre-disposed because of the comorbidities occurring side by side. Now in urology heavy rush is managed by using the face screen and a screen between patients and doctors, besides sanitising and keeping distance. Firstly, the last March onwards tele-counselling has been legalised and if you see a patient you are already examined for the next six months. You can do tele-counselling through any social platform or any dedicated platform. Secondly, we have modified certain guidelines in urology, all OPD indoor, OT protocols and cancer guidelines are modified. In prostate cancer, everybody should treat it once we recognise it is cancer. Unless it is very slow-growing, safe, or low risk but when there is a chance we have to decide whether we are going for a biopsy or not. We have to decide their imaging, not the therapy protocols as we have modified the radiotherapy i.e. the radiation protocols. Also initially there were a lot of apprehends for the laparoscopic surgeries as aerosol spread were also feared. Now because of certain precautions and special protocols we can perform those also. Urological surgeries sometimes are very small as they last for just cystoscopy which is a very short duration and sometimes they are very time consuming and may last for seven to nine hours. We know that in Covid for the long procedure the exposure is long and the viral dose is also high so we have to decide whether we are going for the short procedure, long procedure, short exposure, long exposure and how many times we are calling the patient if we are giving chemotherapy. As Dr Amlesh was saying, that there is target therapy also or the pills for some alternate treatment. Maybe the second line hormones treatments for cancer there are pills. We were preferring that we do not hospitalise the patients and give more of the outdoor treatments and home cure whenever it is possible. What is the effect of Covid on the pre-existing renal or the urological conditions and condition caused by covid? That is also very important as we have identified a lot many biomarkers. If biomarkers are present in the organ we know that these organs are expressed to more damage. Now there are ACE2 receptors. ACE is the angiotensin-converting enzyme that is very important and is present in different organs like the entry point of the nose, eyes, and intestine but in the urological tissues like the kidney, especially in the proximal tubules, they are present. This is the entry point for coronavirus and once they enter through this they start replicating. Therefore, urologists become important because in no previous commodity also patients are exposed to acute kidney injuries which are very serious. If the pulmonary lungs are affected they go high, their morbidity, motility also go high. So maximum acute kidney injuries are occurring in ICUs indoors compared to the outdoor or homecare covid patients and this may have long term consequences. There are certain procedures like kidney stone and we don›t have a table to accommodate them as a lot of OT’s were shut and there are a lot of backlog patients suffering whom we have to take care of. In cancer, radiations like you give the doses you go for hypofractionation means you give small doses. Also in surgeries, we have to decide whether we can postpone the surgery and also there is an effect on fertility because of the inflammatory reactions of the Leydig cells which are important in the spermiogenesis and also because of direct inflammation which is the main problem in covid infection and testis gets damage so fertility gets affected. It has been found that the fertility rates go down, not only that there is another angle another at the end of the spectrum—i.e. because of the undesired conceptions you are not able to go for MTP the Medical Termination of Pregnancy. Due to the different work from home and social conditions in some advanced countries, educated countries, there had been a decrease in the population due to the involvement of mental health also.
Q. Has it affected mental health also?
Dr Rajiv Sood: Yes, it is connected with the population also. In India, it was found that a 3.1% increase in the birth rate and that is called the baby boom. The population is going down and going up in many countries, directly sexual organs and genital organs are getting affected.
Q. Why is infertility increasing in men, especially in the younger generation?
Dr Anup Kumar: The causes for increasing infertility are increased use of alcohol and tobacco in the younger generation. We are also seeing an increase in the trend of diabetes, type 1 diabetes, and hypertension in the younger population. This is all because these are lifestyle diseases and the younger generation do not take healthy food, do not exercise and are having obesity. Just like in the USA an obesity pandemic going on, we can see the number of obese patients in India is also increasing. Other than that, there are some other idiopathic genetic factors also which are increasing infertility cases in India. Therefore, it is very important to have a healthy lifestyle, do not take alcohol and tobacco, workout for at least 30 minutes per day, do not take frozen meat as the meat contains very toxic chemicals which can impair your sperm production, avoid extreme heat exposures as it can lead to the failure of the spermatogenesis. Also, certain chemotherapist drugs can directly affect sperm production. There is a production decrease after the drugs and these patients can preserve the sperms before starting chemotherapy.