Oliver Kayes, Consultant Urological Surgeon, St James’ Hospital, Leeds.
Clinical Visit to Kulkarni Endo Surgery Institute and Reconstructive Urology Centre, Pune, India.
I am lucky to have been appointed to a busy consultant post managing both general urology and complex andrology conditions in Leeds. I believe that urethral reconstruction is a surgical craft; balancing surgical technique, clear decision-making and patient management to achieve optimal outcomes. Undoubtedly, surgical volume and experience remain key factors for achieving the best results from urethroplasty surgery. Currently, urethral strictures affect about 62,000 men in the UK at any one time. Despite, the continued evolution of stricture management from the pioneering era of Richard Turner Warwick (proponent of the “'take it to bits and put it together” technique – TITBAPIT) to current reconstructive strategies; several controversies persist that cause continued debate amongst surgeons. Should you use a graft or a flap? One stage procedure or two? Transecting or non-transecting approach? A strong understanding of the principles for anastomotic and onlay buccal mucosa graft urethroplasty allows surgeons to treat more than 90% of patients with a urethral stricture. Complex cases need experience of the variety of procedures used to reconstruct long segments of urethra or posterior urethral stenosis including: tissue grafting techniques, abdominoperineal surgery, perineal urethrostomy, mitrofanoff placement and, potentially, future tissue engineering capabilities.
Why Pune, India?
The Kulkarni Centre is an international, tertiary referral centre for urethral reconstruction located in Pune, India. A unique hospital and educational setting, this centre performs high volume urethral surgery to over 500 patients per year across all aspects of urethral stricture disease. Tucked away off the busy main street, this small clinic started life as a simple block of flats with an adjoining garage. No chandeliers or marble. No glossy marketing or branding. Dedication, teamwork, thoughtfulness and time have transformed this unusual space into an international focus of one of the world’s highest volume urethral reconstruction surgeons which attracts patients (and surgeons) from all over the globe. It offers unprecedented exposure to typical and complex urethral conditions including multi-stage and revision surgeries. Dr Kulkarni has overseen the training of more than 1000 Indian urologists and many overseas experts over the last decade. He recently received the prestigious B C Roy award for medical teaching from the President of India. It recognizes individuals who have demonstrated national excellence in the field of medical and surgical education. Our teaching was delivered through a combination of high quality live surgical demonstrations illustrating the various urethroplasty techniques supported by face to face tutorials delivered by Dr Kulkarni and his team of senior surgeons. Additionally, he would warmly recount his time training under RTW’s tutelage in London in the mid-1980s and how his practice and techniques have evolved with time and experience.
Secondly, and no less important in my eyes, this visit allowed the opportunity to view medicine and surgery outside of the NHS and my current UK practice. A chance to explore a unique financial and cultural healthcare system attempting to deliver care to 1.2 billion people. To witness the challenges for both physicians and patients whilst reflecting on the fundamental issues faced by the NHS currently. Potentially, this trip offered an opportunity to identify problems and develop some solutions that could improve patient care and experience in one or both countries?
Dr Kulkarni delivering a typically relaxed but thought-provoking academic session
Surgery in India
Upon arrival at the clinic for the first morning of the masterclass, I was struck by the serenity of the clinic amongst the backdrop of the early morning hustle and bustle of Pune life. Just another typical day! I was met with broad smiles and warm greetings from everyone and quickly lost my traveler’s anxiety. The clinical space felt rustic in comparison to modern day Western hospitals but highly efficient with anaesthetic, theatre and recovery teams working in tight synchrony to move patients around the 3 floors of the hospital (without a lift). Surgical demonstrations were augmented by modern, cutting edge audiovisual equipment and the clear mastery of live surgery performed by Drs Kulkarni and Joshi. Clearly, they feel very comfortable and have spent time perfecting the environment and their techniques to afford optimal observation for the surgeons in the room. Cases were processed rapidly with on table diagnostics and peri-operative planning to supplement the expert reconstructions. Cost savings and efficiencies were evident from autoclavable motorbike handles (used as light handles) to the hand-sewn surgical drapes made from parachute material. Bespoke, efficacious and cheap. Over the following weeks, I witnessed and discussed every aspect of urethral surgery from “simple” DVIU to complex pelvic fracture urethral distraction defects (PFUDD). The volumes of cases alongside traditional stone surgery and open pelvic reconstruction was staggering.
A typical urethrogram
Lessons learned
This visit challenged my preconceptions of travelling and working in India. Whilst, experiencing the difficulties of delivering surgical care on the sub-continent, I also managed to allay my own anxieties and concerns of visiting such a magnificent country. Patients often travelled from as far away as Bangladesh to seek advice and help. X-rays tucked under their arm, they would listen intently to the plan and nod appreciatively upon hearing that their case was suitable for treatment. Often this was within 24 hours and at limited cost to the patient. The recognisable benefits of not having a waiting list and achieving autonomy over one’s entire practice. I generated strong links with colleagues both in India and further afield (e.g. Hong Kong, Australia) and we shared our collective experiences and expertise in reconstructive and general urology. It is clear, that with minimal investment we can offer a great deal to surgeons who wish to visit our NHS to observe the methods and case mix typical to a European urologist specializing in andrological and reconstructive surgery. Social media and smartphone applications have now linked me to a wider community looking to share ideas and innovate. Finally, I believe the visit was successful in delivering the opportunity to learn in detail the various techniques of urethroplasty and to take certain facets of each surgery back with me to the UK to help me develop my own practice.
Future directions
I am directly involved in building services that add real value for patients and I want to create a sustainable culture of continuous improvement within the NHS. Complex cases need to be performed in centres of excellence in line with potential changes to commissioning services in NHS in future. This clinical visit has provided a dedicated and protected time for detailed exposure to simple and complex urethroplasty techniques. Currently, in UK, urethroplasty is under-utilised in the treatment of men with urethral stricture disease and we await the results of the OPEN trial to better understand the role of repeated direct visualised internal urethrotomy (DVIU) versus early urethroplasty. Surgeon confidence and experience appear to be strong drivers when offering men either surgery; with high variation between centres as observed in a recent nationwide survey in the USA (Figler et al. J Urol 2015).
In the NHS in England, urethral strictures represent 17,000 hospital admissions annually, including 16,000 bed-days and 12,000 operations at a cost in excess of £10 million (data from OPEN trial). In Leeds, we are developing our services to perform high volume surgery to the standards of a centre of excellence in the NHS. The positive impact for our patients will include: reduced waiting times for surgery, treatment in a locoregional centre, robust outcome reporting through BAUS audit with hopefully improved immediate and long-term functional outcomes alongside reduced complications. In parallel, experiences gained from this visit will translate to improved local networks, staff training programmes and patient education events. I am privileged to have applied and been awarded this prestigious education grant through TUF and will continue to embrace the opportunity to foster links with overseas institutions. We look forward to initiating an exchange programme to allow surgeons from India to visit and work in Leeds in order to observe contemporary andrological surgery. I am extremely grateful for the financial support received from The Urology Foundation.
Oliver Kayes
April 2017
