Surgical Sperm Retrival:

Azoospermia meaning absence of Sperm in the semen. This can commonly Obstructive Azoospermia because of block in the epididymis or in the vas either because of injury, infection or surgery. Azoospermia could also be caused by failure of production of sperm called Non obstructive azospermia. In these case Sperms can be retrieved by surgical techniques.

Microsurgical Epididymis Sperm Aspiration (MESA): By this technique epididymis is opened by fine dissection and sperms are aspirated by a fine needle from the epididymis. It is a day care procedure, done in the operation theater with facility of sperm freezing.

Testicular Sperm aspiration (TESA): This is similar to the other technique but the testes is aspirated from the testes. Finding good number of sperm in testes is not as good as in epididymis.

Sperm extracted in these methods are frozen and later used for Intra Cytoplasmic Sperm injection ICSI.

Article By
Fortis Hospital

Polycystic ovary syndrome (PCOS) is a common condition affecting 6-7% of women in the reproductive age group. This syndrome is often diagnosed if any two of the following three symptoms or signs are present: absence of periods or irregular periods associated infrequent or no release of eggs every cycle or every month (anovulation or oligo-ovulation), a raised level of male hormone (testosterone) with presence or absence of associated symptoms such as acne, oily or greasy skin, excess hair growth and presence of polycystic ovaries (ovaries with many small cysts of 2-9 mm in size) on ultrasound scan. Although polycystic ovaries are seen in 20 – 33% of women, majority of them are healthy, ovulating normally and not having PCOS.

Causes:
Weight gain or obThe exact cause of PCOS is not yet clear. Whilst PCOS may run in families and several genetic factors have been implicated with its development, not all women with a genetic trait will develop the condition. However, one of the main underlying problems appears to be ‘insulin resistance’. This means that cells in the body such as muscles are resistant to the effect of a normal level of the insulin hormone secreted by the pancreas. Insulin is a hormone that is responsible for control of the blood sugar in your body. The resistance to the insulin effect in these individuals is compensated by an increased production of insulin to keep the level of sugar in the blood normal. The resultant increase in insulin levels in the blood act on the ovaries as well leading to increased production of the male hormone testosterone. A high level of testosterone slows the normal development of follicles or eggs in the ovaries resulting in an abnormally large number of small follicles, which remain immature and subsequent ovulation (release of egg) is hampered.

Short term and long term problems associated with PCOS:

Weight gain or obesity is not a consequence of PCOS however obesity or excess weight gain tends to worsen the manifestation of this syndrome. Excess body fat can also make insulin resistance worse, leading to further elevations in blood insulin concentrations with a progressive burn out of the gland producing the hormone.

Women with PCOS may develop symptoms in their late teens or 20s. Symptoms can vary from mild to severe and may change over the years. Apart from period related problems, which affect 7 in 10 women affected with PCOS, unwanted hair growth may occur over face, lower abdomen or chest depending on the degree of the rise in testosterone levels. Acne and thinning of scalp hair may also occur. 40% of women are obese and this may be secondary to increased insulin levels. Because of the disturbance in ovulation associated with PCOS, most women experience subfertility although majority of them conceive following treatment of stimulation of the ovaries using fertility drugs.

Nearly 10-20% of women with PCOS develop diabetes at some point in their life. The risk is increased if women are obese (body mass index more than 30), have a strong family history of type 2 diabetes or are above 40 years of age. Women who have been diagnosed as having PCOS are more likely to develop diabetes during pregnancy. A sleeping problem called sleep apnoea, a condition associated with snoring, is also more common than average in women with PCOS. They are also at increased risk of having a stroke and heart disease in later life because of the problems described above in addition to other associated conditions such as obesity, raised blood pressure and increased cholesterol levels. If women suffer from infrequent periods particularly with intervals between menstrual cycles of more than three months, the risk of pre-cancerous changes and subsequent cancer of the lining of the womb is higher than women having regular menstrual cycles. Because of these associated risks women having PCOS should have regular checks for blood sugar, cholesterol levels and blood pressure to detect any abnormality as early as possible. They should also be advised to have at least four menstrual cycles, which could be induced by taking either the ordinary contraceptive pills or progesterone tablets as prescribed by a doctor to prevent any changes within the lining of the womb.

Curing PCOS:

Whilst there is no cure for PCOS, life style and dietary modification may alleviate some of the symptoms and long term consequences. Weight loss and regular exercise in obese women have been shown to improve fertility and lowering of androgen levels and associated symptoms of hair growth and acne. It also reduces the long term risk of diabetes, heart disease and even cancer of the lining of the womb. Even a small reduction in weight of about 2-5% has been shown to improve the ovulation and resumption of menses. Dietary modification such as low calorie diet, avoiding sugary drinks and also snacks between meals are useful to complement the efforts to reduce weight. Small frequent low calorie diet may be an alternative to avoid persistent increase in insulin levels, which is the key mechanism for the development of most symptoms of PCOS (make your portions small). Daily moderate sweat inducing exercise lasting for at least 30 minutes is one of the most important lifestyle measures to reduce the risks of both the short term and long term consequence of PCOS.

Article by

Fortis Hospitals

The lining of the womb or uterus is called endometrium. Endometriosis is an estrogen hormone-dependent condition that is characterized by the presence of ectopic endometrial tissue in places within the body but outside of the uterus. The disease state and symptoms can be modified by pregnancy, breast feeding and menopause.

The pathogenesis of endometriosis remains an enigma in gynaecology and a topic of heated debate. There are 2 distinct entities:

Endometriosis (external – outside of the uterus)
Adenomyosis (in the muscle of the uterus).

Diagnosis:

A good clinical history and a thorough clinical examination help point in the direction of the correct diagnosis. To confirm the diagnosis, a woman will be advised to undergo a pelvic ultrasound assessment and laparoscopy (keyhole camera procedure) which is considered the “gold standard” tool. Other sophisticated tests such as MRI, intravenous urography (IVU), barium enema (X-ray procedure) may be required in some women with severe disease.

Treatments:
Endometriosis can be managed either with the help of drugs or with surgery. The drugs used for the management are geared towards reducing the impact of the oestrogen hormone.

Unfortunately, one cannot completely cure endometriosis or eradicate the disease by surgery or medications.
Following surgery for mild, moderate or severe disease, the chances of recurrence may be as high as 50% in 2 – 3 years. Also, symptoms of pain may recur once the medications are stopped.

Drugs:
Painkillers
Combined oral contraceptive pill (COCP)
Progesterone only pill
Gonadotropin releasing hormone agonist (GnRHa e.g. Zoladex, Prostap, Luprolide acetate etc)
Mirena IUS (Progesterone loaded IUCD)

Initial management of pain symptoms is generally with painkillers or analgesics. If a woman is not desirous of fertility and pain is her main symptom, the use of the combined oral contraceptive pill continuously for 3 – 6 months followed by short breaks of 7 days could help relieve the symptoms.
In women that are overweight or obese, those that have a family history of blood clots, or those that smoke and those with an altered liver function, the use of oestrogen containing pills is contraindicated. In such cases, one may use the progesterone only pill continuously for 3 – 6 months.

GnRH analogues are injections that will be given to cases with moderate to severe endometriosis. These injections are given either or a monthly or 3 monthly basis. The GnRH analogues temporarily switch off the ovaries thereby reducing the impact of oestrogen on the endometriotic deposits and causing a regression in their size and improvement in the pain symptoms. Women may need to use a small dose of hormone replacement therapy (HRT) during the GnRH analogue treatment to combat symptoms of low oestrogen such as hot flushes, night sweats, mood swings and irritability.
The Mirena IUS is a progesterone (levo-norgestrel) loaded intra-uterine device that has been found to have a beneficial impact on symptoms of pain.
Unfortunately, none of the above will allow a woman to conceive or fall pregnant during treatment.
Article by
Fortis Hospitals

Chronic pelvic pain is defined as pain the abdomen / pelvis below the level of the belly button (umbilicus) that has been present for 6 months or more.

It may or may not be associated with menses or periods. It is not a disease but a symptom that can be caused several different conditions.

Diagnosis:

Detailed history
Clinical examination
Blood tests
Urine test
Pelvic Ultrasound
Laparoscopy (key hole camera procedure through the belly button)
Others: CT scan, MRI scan.

Medical Managements:

Pain killer tablets (Paracetamol, Ibuprofen, etc)
Hormonal manipulation (Endometriosis / fibroids)
Surgical treatment of endometriosis / fibroids / adhesions or scarring
Relaxation techniques / hypnosis
Psychosocial support and counselling (Individual therapy / group therapy / patient support groups)

Article by
Fortis Hospitals

Pelvic inflammatory disease (PID) is a disease of the upper genital tract seen in women between 15 – 45 years of age and involves uterus (womb), fallopian tubes, ovaries and other areas within the pelvis. The infection affects the surface lining in all the above organs leading to damage with short and long term health implications.
The true prevalence of PID is unclear but it is known that nearly 1:50 women will see their GP with some symptoms due to the disease process. The common organisms associated with PID are Chlamydia trachomatis and Neisseria gonorrhoea. The other organisms that cause pelvic infection include Anaerobes, Mycoplasma genitalium, genital Tuberculosis etc.
Screening programes have revealed that asymptomatic Chlamydial infection can be picked up in as many as 6% women seeking contraception advice and up to 5% women undergoing cervical smear test (PAP smear). Overall screening programmes have shown a pick up rate of between 1-17% in asymptomatic women.

Diagnosis:
The doctor will obtain a history and perform a clinical examination during which culture swabs will be taken from cervix (neck of the womb) and vagina to confirm the type of infective organism. This will be followed by blood tests, pelvic ultrasound scan and sometimes laparoscopy (camera procedure through the belly button). Genital Tuberculosis of the uterus can be confirmed following laboratory analysis of the endometrium (biopsy of the lining of the womb). Currently there is no single test that will accurately diagnose the presence of PID.

Medical Management:

Prevention – Safe sex education in schools and colleges, changing or modifying behaviour, programmes for screening of infection in the population
Oral drugs – prompt treatment for the infected individual with appropriate drugs for a prescribed time period
Contact tracing of sexual partners and treatment
Hospitalization, Intravenous drug therapy and surgery (laparoscopic / open) for severe cases and especially those that develop abscesses in the tubes and ovaries and also that fail to respond to standard oral drug therapy
In the future vaccination for prevention

Article by

Fortis Hospitals

The ankle-brachial index test is a quick, noninvasive way to check your risk of peripheral artery disease (PAD). Peripheral artery disease is a condition in which the arteries in your legs or arms are narrowed or blocked. People with peripheral artery disease are at a high risk of heart attack, stroke, poor circulation and leg pain.

The ankle-brachial index test compares your blood pressure measured at your ankle with your blood pressure measured at your arm. A low ankle-brachial index number can indicate narrowing or blockage of the arteries in your legs, leading to circulatory problems, heart disease or stroke. The ankle-brachial index test is sometimes recommended as part of a series of three tests, including the carotid ultrasound and abdominal ultrasound, to check for blocked or narrowed arteries.

The ankle-brachial index test is done to check for peripheral artery disease (PAD), a condition in which the arteries in your legs or arms are narrowed.

Ask your doctor if you should have this test if you are age 50 or older and have any of these risk factors for PAD:

Being a current or former smoker
Diabetes
Overweight (a body mass index of 25 or greater)
High blood pressure
High cholesterol

If you’ve already been diagnosed with PAD, your doctor may recommend having an ankle-brachial index test to see if your treatment is working or if your condition has worsened. If you have symptoms of PAD, your doctor may suggest you have an exercise ankle-brachial index test to determine if your symptoms are due to PAD or other conditions, such as spinal stenosis. In an exercise ankle-brachial index test, you walk on a treadmill for a short time before your ankle-brachial index is measured.
When the ankle-brachial index test is complete, your doctor calculates your ankle-brachial index by dividing the higher of the two blood pressure measurements at the arteries near your ankle by the higher of the two blood pressure measurements at your arms. Based on the number your doctor calculates, your ankle-brachial index may show you have:

No blockage (1.0 to 1.4). An ankle-brachial index number in this range suggests that you probably don’t have peripheral artery disease. But if you have certain risk factors, such as diabetes, smoking or a family history of PAD, tell your doctor so that he or she can continue to monitor your risk.
Borderline (0.9 to 0.99). If your ankle-brachial index number is less than 1.0, you may have some narrowing of the arteries in your leg. People with an ankle-brachial index of 0.9 or lower may have the beginnings of PAD. Your doctor may then monitor your condition more closely.
Mild blockage (0.8 to 0.89). An ankle-brachial index in this range shows you’re in the early stages of PAD. Your doctor may suggest medications or lifestyle changes to treat your condition.
Moderate blockage (0.5 to 0.79). An ankle-brachial index number in this range shows that you have more significant blockage of your ankle and leg arteries. You may have noticed some pain in your legs or buttocks when you exercise.
Severe blockage (less than 0.5). If your ankle-brachial index number is in this range, your leg arteries are significantly blocked and you may have pain in your legs even while resting. An ankle-brachial index of less than 0.4 suggests severe PAD.
Rigid arteries (more than 1.4). If your ankle-brachial index number is higher than 1.4, this may mean that your arteries are rigid and don’t compress when the blood pressure cuff is inflated. You may need an ultrasound test to check for peripheral artery disease instead of an ankle-brachial index test, or a toe-brachial index test, in which the blood pressures in your arm and big toe are compared.

The above numbers are based on guidelines Mayo Clinic uses. The guidelines suggested by the American Heart Association and the American College of Cardiology differ slightly. They suggest a normal ankle-brachial index ranges from 1.0 to 1.4, a borderline index ranges from 0.91 to 0.99, and an abnormal index is 0.9 or lower. If you have an exercise ankle-brachial index test, the ranges for results differ. Talk to your doctor about what your results mean.

Depending on the severity of your blockage, your doctor may recommend lifestyle changes, medications or surgery to treat PAD. Talk to your doctor about your options. You may also need additional imaging tests to see what treatment is best for you.

The test may not adequately measure the ankle-brachial index if you have severe diabetes or calcified arteries with significant blockage. Instead, your doctor may need to read your blood pressure at your big toe (toe-brachial index) to get an accurate test result if you have either of these conditions.

Article by;
Fortis Hospitals

Results:

Medical Therapy:

The medical management of penile trauma is limited and usually depends on surgical optimization of the patient in preparation for the operating room. Penile trauma is often accompanied by other associated injuries, some of which may be life-threatening. Fluid resuscitation and stabilization of the patient should be the focus. Administration of preoperative antibiotics should be considered in patients with open wounds.

If penile reconstruction must be delayed in the setting of a urethral injury, suprapubic urinary diversion may be performed. If surgical therapy must be delayed, initial medical therapy consists of cold compresses, pressure dressings, and anti-inflammatory medications, followed by definitive surgical therapy.
Penile amputation

Pretreatment of the patient with an amputated penis has unique requirements. In the face of an acute psychotic episode, psychological stabilization is required, often with the aid of a psychiatrist. Management of the amputated penile remnant is imperative to a successful reimplantation. The severed penis should be cleaned of debris and wrapped in sterile, saline-soaked gauze. The wrapped penis should be placed into a sealed bag and placed inside a second container filled with an ice-slush mix. This helps to reduce the ischemic injury to the severed penis. Reimplantation should be performed as quickly as possible.
Penile soft tissue loss

Bite injuries to the penis require extra care, as they have the potential for infection with unique organisms. Dog bites, the most common animal bite, consist of multiple pathogens such as Staphylococcus and Streptococcus species, Escherichia coli, and Pasteurella multocida. Antibiotic treatment should generally include oral dicloxacillin or cephalexin. Patients with possible Pasteurella resistance can be treated with penicillin V. Chloramphenicol has also been shown to have good efficacy.

Human bites are considered infected by definition and should not be closed. They can be treated with antibiotics similar to those used in animal bites despite the fact that bacterial cultures may differ.

Surgical Therapy

No matter the form of penile trauma, the goals of surgery for the traumatized penis are universal: restore the penis to its preinjury state, prevent erectile dysfunction, maintain penile length, and allow normal voiding.[9, 10, 11]
Penile fracture

In the reported literature, surgical therapy has consistently resulted in fewer complications. Muentener et al reported good outcomes in 92% of patients treated surgically versus only 59% in those treated conservatively. In addition, surgery provides good outcomes after varying timing of presentation after injury. A study by El-Assmy et al found no substantial difference in recovery based on early or delayed presentation of penile fracture with subsequent surgery. Patients were divided into group I early presentation (1-24 hours after injury) and group II delayed presentation (30 hours to 7 days after injury). Mean follow-up was 105 months for group I and 113 months for group II.[12]

Principles of surgical therapy are as follows:

Optimize the surgical exposure.
Evacuate the hematoma.
Identify the site of injury.
Correct the defect in the tunica albuginea.
Repair the urethral injury.

Three types of incisions are generally used to repair penile fracture: incision directly over the defect, circumscribing-degloving incision, and inguinal-scrotal incision.

An incision directly over the identified defect in the corpus cavernosum allows minimal dissection of neurovascular bundles but does not afford complete evaluation of both the corpora cavernosa and the corpus spongiosum. The authors do not advocate this type of entry. A circumferential-degloving incision begins 1 cm proximal to the coronal sulcus and affords excellent exposure. However, decreased penile sensation has been reported with this type of incision. The inguinal-scrotal incision provides excellent exposure of the base, root, and dorsal surfaces of the penis. If necessary, the entire penis may be averted inside out to maximize surgical exposure.

At the authors’ institution, a circumferential-degloving incision is routinely used with excellent results. On occasion, the authors have also used an inguinal-scrotal incision for more complex injuries located near the base of penis.
Penile amputation

An amputated penis should be immediately and expeditiously repaired to prevent further ischemic injury to the penile remnant. This should be undertaken at a center of excellence, and the patient should be stabilized and transferred if a reconstructive urologist or plastic surgeon is not available at the presenting institution.

Principles of surgical therapy are as follows:

Optimize the surgical exposure.
Judiciously debride necrotic tissue.
Anastomose the severed urethra over a Foley catheter to provide stabilization.
Repair the tunica albuginea.
Use microsurgery to repair the dorsal nerves, arteries, and veins of the penis.

Penetrating injury

Expeditious surgical repair of the penis should be undertaken as soon as possible.

Principles of surgical therapy are as follows:

Optimize the surgical exposure.
Judiciously debride necrotic tissue.
Repair injured urethra.
Repair tunica albuginea injuries.

Penile soft tissue injury

Surgical repair should be initiated as soon as possible in soft tissue injuries. This prevents colonization of the wound. The only exception is that of the human bite because of the high risk of polymicrobial infection.

Principles of surgical therapy are as follows:

Debridement of necrotic tissue
Copious irrigation of wound with povidone iodine and antibiotic solution
Closure of injury with exception of human bites
Skin grafting and harvest to cover large defects

Article by
Apollo Hospitals

Single Port Endoscopic technique of Carpal Tunnel Release (ECTR)

Carpal Tunnel Syndrome is a medical condition where in people suffer from numbness, pain and discomfort in the hand accompanied by tingling, burning, numbness, weakness of hand grip or simply pain. It is caused by the gradual strangulation of the Median nerve by the surrounding structures coursing within the carpal tunnel of the wrist, leading to nerve entrapment symptoms. These are usually felt over the thumb, index and middle finger, though the pain may extend up to the shoulders.

One in every five people suffering from such symptoms can be expected to have CTS following a thorough clinical examination, imaging and electrophysiologic (Nerve Conduction) studies. If untreated, it may result in permanent nerve damage causing constant numbness, wasting of the muscles of the hand involved in thumb movements.

This condition may affect both hands, though symptoms may predominate on one side. In early stages, the symptoms are intermittent in nature and usually occur at night times, the possible explanation being the flexed position of the wrist joint during sleep. However, the numbness can be intense enough to wake one from sleep.

Non surgical treatment includes the use of night splints, steroid injection, oral anti-inflammatory and analgesic drugs. However, for acute cases, surgery is the only option. Done under local anesthesia, the procedure itself doesn’t last more than half an hour, though an added mild sedation of the patient does help in making it quicker.

With the aid of an optically linked video monitor and Smart Release device in this single port endoscopic technique of carpal tunnel release, the surgeon precisely cuts the transverse carpal ligament from underneath using a retractable blade, without cutting open the entire palmar skin. Once done the blade retracts and the endoscopic instrument is withdrawn. The less than 1 cm skin incision is closed with absorbable sutures.

The resultant cosmetically acceptable scar is small and concealed within the wrist skin crease. Patients have the advantage of returning to work after surgery within eight days or earlier.

Article by.

Apollo Speciality Hospitals, Teynampet, Chennai. Dr (Major) GB Rajan, Consultant Plastic Surgeon, Apollo Speciality Hospitals, Teynampet, Chennai.

Procedure Details

An automated implantable cardioverter-defibrillator (AICD) is a tiny electronic device implanted in the chest to prevent sudden death from cardiac arrest caused due to fast heart rhythms (tachycardias).

The AICD is capable of monitoring the heart rhythm to identify abnormal heart rhythms and determines the appropriate therapy to return your heartbeat to a normal heart rhythm.

The patient is admitted for 1 to 2 days for the AICD implantation. The implant procedure usually lasts about one hour and is performed in the Invasive Cardiac Laboratory. As it is very important to keep the area of insertion sterile to prevent infection, sterile drapes will be used to cover the patient from neck to feet. A small plastic cannula will be inserted in one of the veins on the hand to facilitate injection of medication. Just before implantation, the patient will be given an injection of an antibiotic to prevent wound infections. He/she will also receive medication through the intravenous cannula. After injection of a numbing medication, a small incision (cut) is made in the upper left chest (if you are right-handed) and a small pocket is created under the skin to accommodate the pulse generator. The lead is then inserted through a vein in the upper chest and is positioned under X-ray guidance until its tip lies snugly within the heart. The other end of the lead is then connected to the pulse generator. Your doctor may have to test the AICD by inducing an abnormal heart rhythm in the laboratory and observing if the AICD functions as expected. The patient will be put to sleep with medication before the test. The incision wound is then stitched up, cleaned and a waterproof dressing applied to the wound.

Most patients can be discharged one to two days after the implantation.

Article By

Manipal Hospitals

What is Shoulder Fracture Reduction?

The term reduction indicates restoration of a fracture or dislocation of the bone back to its normal anatomic location.

Who is a candidate for Shoulder Fracture Reduction & Fixation?

Following patients are usually candidates for shoulder fracture reduction surgery:
Patients with comminuted fractures.
Proximal humeral dislocated fractures.
Fractures with displacement.
Glenoid (shoulder socket) involvement.

How is the procedure performed?

During open reduction and internal fixation, under the effect of anesthesia, the broken bones are put back into their normal anatomical position. Fixation is done internally using pins, screws, or bands. The incisions are then closed with stitches and sterile dressing is placed.
Closed reduction procedure placing fragments of bone back into their normal anatomic position and then external fixation with sling is used to keep them in place which is removed later on.

How long does the hospital stay last?

Most of the patients need to stay in hospital for about 2 to 3 days depending on surgeon’s discretion.

What would be done for pain relief?

Pain medications are administered per the patient requirements. Oral pain medications are continued in the recovery period as long as the patient continues to need them.

What should be expected in the postoperative period/rehab?

Pain management is designed per the patient’s requirement.
Necessary precautions and medications would need to be taken.
Immobilization of arm would be done with sling.
Wound care and bandaging would be advised.
Bathing advice would be given by the surgical team.
Balanced diet with iron supplements to promote healing would be advised.
Intake of plenty of fluids to maintain hydration.
Physical therapy is very crucial for successful recovery of the patient. Under the guidance of physical therapist, the patient is instructed exercise to help with strengthening and mobility. Also exercise helps reduce swelling and stiffness of the joint.

What are the advantages of procedure?

Fracture reduction results in placing bones back to their normal anatomical position which is very important in order for the joint to function properly without pain.

What is the outcome of Shoulder Fracture Reduction & Fixation?

With advancement of surgical techniques, appropriate treatment that is rendered yields excellent results for most of the patients.

Why NOSH for Shoulder Fracture Reduction?

NOSH is a doctor owned hospital and consequently attracts the top talent available in the country. NOSH has the best Orthopedic doctors and surgeons for Shoulder Fracture Reduction in India. Equipped with the state-of the-art infrastructure and latest high-end technology, NOSH is the best Orthopedics hospital for Shoulder Fracture Reduction in Delhi, India.