NEWSLETTER OFFICIAL NEWS BULLETIN OF UROLOGICAL SOCIETY OF INDIA - WEST ZONE
“ change we can”
Lasers in Urology
Water and We
Dr Peter Alken Speaks
Editorial Dear Members,
information is missing or incorrect, please inform secretary's office by phone, sms, email or post. We want to make our directory uptodate & flawless.
We are pleased to release second issue of this years' newsletters.
We have continued our trend of interviewing “ICON UROLOGIST” of international repute. I hope you will enjoy the talk with Peter Alken- a trendsetter in PCNL. The debate has also become an integral part of newsletters & lot of members have liked it. Rupin Shah & Brajesh Singhal have debated on an interesting topic.
At the outset we are happy that many members are coming forward to contribute towards the newsletter. You will see articles written by different members in this issue. We hope this trend continues & we get contributions from many members.
Please let us know your views & suggestions. We once again thank Intas Pharmaceuticals for sponsoring this newsletter.
It is our dream to have all member’s correct e-mail id. Still lots of member's details are incorrect. Please check the label on the cover of this newsletter. Apart from address, it contains your USI membership no & status (full / assoc), birth day, mobile no and e mail id. If some
Council Members Details West Zone details : President : Dr. S.W.Thatte President elect : Dr. Ajit Vaze Past President : Dr. Deepak Kirpekar Hon.Secretary : Dr. Ravindra Sabnis Hon.Treasurer : Dr. Umesh Oza
Mobile : 09820095112 Email: email@example.com Mobile : 09821023637 Email :firstname.lastname@example.org Mobile : 09822022842 Email : email@example.com Mobile : 09426422002 Email : firstname.lastname@example.org Mobile : 09820058623 Email : email@example.com
Council members : Dr. Jaydeep Date Dr. Hemant Pathak Dr. Hemant Tongaonkar Dr. Subodh Shivde
Mobile : 09822040813 Mobile : 09820364294 Mobile : 09820073911 Mobile : 09822217380
Ex officio members Dr. Makarand Khochikar Dr. Jaikishan Lalmalani
Mobile : 09822052731 Email : firstname.lastname@example.org Mobile : 09820071046 Email : email@example.com
Email : firstname.lastname@example.org Email : email@example.com Email : firstname.lastname@example.org Email : email@example.com
Secretariat : Dr. Ravindra B. Sabnis Vice Chairman, Dept. Of Urology, Muljibhai Patel Urological Hospital, Dr.Virendra Desai Road, NADIAD-387 001, Gujarat Tel.:0268 2520323 to 30, Fax : 0268 2520248, Mob.:9426422002, Email : firstname.lastname@example.org
From the President’s Desk..........
Dear Members, The year's activities have taken a definite shape and we seem to be heading in the right direction. In my previous communication to all of you I had urged you to keep the 'Patient Care phenomenon' uppermost, while continuing with our handling of day to day responsibilities. We are holding a Uro Patient Care camp at Gondavale near Satara in Maharashtre on 15th and 16th Aug 09 and will be performing all endoscopic procedures. the underprivileged ! Yes, they need us ! We need to go out to them to give them the best of the treatment at affordable cost. We have made a beginning on this year's theme Patient care. May I request all others who wish to be part of this project to kindly get in touch on email with me. Immediately after rains, we intend to look for another window of opportunity to help the needy. . The stage is slowly getting set for the Annual event at Khajuraho this winter- WZUSICON 2009. The local bodies are leaving no stone unturned ( there are many artefacts on stone to be seen at Khajuraho ! ) for making the event memorable. We do work in proximity of stones. The Khajuraho group of monuments have been listed as a UNESCO World Heritage Site. Khajuraho has the largest group of medieval Hindu and Jain temples, famous for their erotic sculpture.The name Khajuraho, ancient "Kharjuravahaka", is derived from the Sanskrit word kharjur meaning 'date palm'. So, remember your Date with Khajuraho. I am sure all of you would be able to contribute in some form or the other and reap the benefits of harnessing knowledge and sharing experiences during the networking lunches and dinners. Go ahead make new friends just walk up to someone whom you don't know , leave your inhibitions behind and say “ Hi Doc !” - the rest will get etched on stones in history ! You would recollect my previous communication to you in this column, I await your feedback and views on issues which need to be taken on collectively by our society. Do let your imagination do a bit of digging up the grey matter and give us your views/suggestions/difficulties. I
promise I shall handle these individually and ensure that we collectively can reach better heights. An idea can change the way we handle things. So “ Sirjee, What an idea !” should not be only for the mobile companies even we can generate some excellent ideas which are hibernating in corners of our fertile brain. Well then, pick up a pen or the mouse on the PC and let the thoughts be translated into words and then words into action. I shall wait your communiqué at email@example.com . Dr Sadanand W Thatte Lastly, let me leave you with a fine quote I read a few days ago ..... Formerly, when religion was strong and science weak, Men mistook magic for medicine; now, When science is strong and religion weak, Men mistake medicine for magic. ~ Thomas Szasz, The Second Sin, 1973
Council Members Details
From the President’s Desk
From Honorary Secretary’s Desk 4 WZUSICON 2009 Secretary’s Desk 4 Khajuraho Scientific Program
Peter Alken’s Interveiw
Lasers in Urology
Water and We
Obituary- Dr Atul Thakre
West Zone Programes
....Words from Honorary Secretary
Org Secretary WZUSICON 2009 Dear Members ,
Registration for Khajuraho conference is excellent & I Happy Independence day & Greetings am extremely thankful to all of you for the faith you have from Nadiad! shown in us. I assure you that we will not let you down. WZUSICON 2009 at Khajuraho is from 19 to 22 Nov. More than half of the year is over & I am happy to inform This is the residential conference offering attractive you that we are progressing well on several fronts. packages. Please visit www.wzusicon2009.org for all the details. It was our efforts for long time to organise some Approach to Khajuraho is by multiple ways. The nearest academic activity in Chattisgadh under the auspices of stations on main line are Jhansi & Satna. Pick up is west zone. I am happy to inform that Urological society of arranged from these stations. Khajuraho has chattisgadh is formed & they organised CME on 14 June international airport. There are 2 flights daily from Delhi along with USIWZ. Another academic activity in the form to Khajuraho, which reach at around 1 pm. To these of video operative technique course was organised for flights there are connecting flights from Mumbai, Ahmedabad or Pune. There are no direct non-stop post graduate students at Pune. Both these activities flights to khajuraho from anywhere else. You have to were very successful. Please see the details in this come via Delhi. issue. Most economic way to reach Khajuraho is via train to Jhansi or Satna. Delegates around Nagpur, Bhusawal, We have lot many programs lined up culminating into our Manmad, nasik can catch convenient train to jahnsi. annual conference at Khajuraho in November. There are direct trains from Mumbai to Jhansi or Satna. Organising committee headed by Dr. Subhash Chaubey Other alternate route can be via Bhopal. You can reach & Dr. Brajesh Singhal is making excellent arrangement Bhopal either by flight or train. There are direct early at Khajuraho. I am extremely thankful to all the delegates morning flights from Ahmedabad & Mumbai to Bhopal from there you can catch train to Jhansi(4 hrs). From for unprecedented responces. 2 main hotels are already Jhansi you will be picked up. There are plenty of trains full so third hotel was aquired & even that is almost full. bet Bhopal & Jhansi. You can book them well in advance. We are negotiating with other hotel to cope up with For people from Ahmedabad/Vadodara you can catch registration which are still pouring in. We donâ€™t want to Sarvoday express (No2743) reach Delhi early morning deny anyone but register at earliest to avoid & then catch Delhi Bhopal Shatabdi (No 2002) upto Jahnsi. From there you will be picked up. Or you can take disappointment. I have no doubt that, this time we shall last flight from Ahmedabad to Delhi & catch Shatabdi have record breaking attendance. from Delhi to jahnsi. Reurn also can be planned from jahnsi or satna. For Mumbai delegates, to & fro can be Scientific committee is also taking extra efforts to make planned from Satna by Howrah mail via Alahabad (No 2321 & 2322) scientific program unique & different. 3 major symposia are planned on practically relevent topics. Lot many Thus by selecting one of these means, it is easy to reach interactive sessions will be very useful. Please see the Khajuraho. If you have any query, please contact me detail program given in this issue. Those who have (09425116890 or firstname.lastname@example.org). I will tell already registerd, please do the travel bookings at you most ideal way to reach from your hometown. Please make sure that you do reservation at earliest. earliest. Those who have not yet registered, please don't There is tremendous rush for trains as well as flights miss this opportunity of scientific feast, relaxation, during those days as apart from delegates, lot of trade socialisation in a 5 star environment at such a people are traveling to Khajuraho. economical package. Hotel Clarke & Hotel Redisson are fully booked. In Hotel Ramada inn also very few rooms are available. So As I have always requested, please send your those who have not yet registered please do that suggestions, inputs, and criticism to my office. They all immediately or else you will have to face disappointment. will be treated with respect. Eager to see you at Khajurahoâ€Ś!
Dr. Ravindra Sabnis Hon. Secretary, USIWZ
Dr. Btajesh singhal
WZUSICON 2009 Khajuraho Scientific Program Tentative Thursday - 19th November 2009 Fishing in troubled water Complex cases will be selected. In depth discussion will be done. Audience can actively participate. This sessions is intended to give you practical relevant points that can be implemented in your day to day practice. 06.00 to 06.45 pm Medical management of BPH Do we have problem of plenty? How to make a choice Whether single drug is better or combination? What are scientific basis in selecting drug? All such practical points will be discussed 07.00 to 08.00 pm Inauguration 08.00 pm onwards Cultural program & theme dinner 05.00 to 06.00 pm
Friday 20th November 2009 10.00 to 10.30 am 10.30 to 11.00 11.00 to 11.30 11.30 to 01.30
01.30 to 02.30 02.30 to 03.30 03.30 to 04.15 04.15 to 05.00 05.00 to 05.30 08.00 onwards
Buying a nephroscope How to select Several companies have nephroscopes wolf, storz, Olympus..etc. This session will present comparative analysis of all scopes with respect to size, channel size, design, optics, durability, price……etc Small fight resident debate Big fight Consultant's debate Flexible URS Symposium This symposium intends to cover all practically relevant points like which instruments are good? what should be size of Flex. URS? How much to dilate? Is access sheath necessary? How much is wear & tear? How to increase longevity? Is it cost effective? Which laser to use? Are there differences in laser of diff companies? All tricks of trade. This session is intended for those who want to start & those who have just started performing RIRS Lunch Urology Quiz What went wrong where…..? Case discussions where complications have occurred how to prevent / what more could have been done? This session focused more on managing & preventing complications of various procedures. This will be in form of discussions, video clips Mock Trial Know your guru…..!! Theme dinner
Saturday 21st November 2009 09.30 to 10.00 am 10.00 to 10.30 10.30 to 11.00 11.00 to 11.30 11.30 to 01.30 01.30 to 02.30 02.30 to 04.30 04.30 to 05.00 05.00 to 05.30 5.30 onwards 08.30 onwards
Speaker's corner First 5 winners of Quiz will be given topic on which they have to speak extempore 5 mins each Dr. V.V.Desai oration Dr. A.N.Gaikawad oration Learning & doing lap donor nephrectomy How to kick start…? Session will give thrust on how much experiences is needed, What instruments are needed, What are special precautions? What are legal implications? Symposium on Rising PSA After radical prostatectomy, what are the implications of rising PSA & how to mange, what Other situation, PSA rises. How to investigate - All aspects will be discussed. Lunch Free papers Parallel sessions in multiple halls Evaluation & management of ejaculatory dysfunction To be announced later AGM Banquet
Sunday 22nd November 2009 09.30 to 10.00 am 10.00 to 11.30 11.30 to 12.00 12.00 to 12.30 12.30
Radial AVF - why it fails & what next? Vascular access failure is common problem. This sessions intends to go in depth what causes failure & what are various options with technical details Conf symposium Male sexual health Use of small Bowel in Urology Medical management of male infertility Lunch & disperse
Interview- Peter Alken Mr. Peter Alken a name all of us are so familiar with. He is one of the major contributors in inventing PCNL. His pioneering work on PCNL has changed the way we look at the stones now. PCNL is his biggest contribution to the fraternity of Urologists & to the millions of patients who have undergone this procedure all over the globe. Several inventitions of instruments are to his credit to name the few, Alken needle & sheath, Alken rod, alken telescopic dilator system…etc.
Q: Sir, you are the pioneer of PCNLs in the world. How did you invent the procedure? How did you get this idea? A: I had one radiologist friend. He started doing PCNs. Mainly to drain pus, see the function…etc. Then we thought we should do something more than this. This was in 1976. Then we started dilating the tract. It was very clumsy. We used to dilate every 3rd day. Tubes used to slip out. Pts used to be in ward for 2-3 months. We used to put scope inside & have a look. That is how PCNL started.
Mr.Peter Alken recently retired as Head and Chairman, Dept, of Urology, University Clinic Mannheim, Hiedelberg Medical School, Germany. He is on editorial board of Several Journals. He has several publications in International Journals - many of them are of pioneering work. He has written many books and received innumerable awards and medals.
Q: Did you feel like giving up any time? A; Not really. But there were lot of problems. Improper tubes, improper instruments. But both us were determined that we should do something & we continued. One day we were doing ultrasound scan. It was a compound scanner. We could see the PC system & could puncture under ultrasound control. Then things Recently he visited Nadiad to conduct a course on became easy & we never looked back. PCNL. I had opportunity to talk to him. These are some of the excerpts from the interview. Q: How did you get the idea of designing famous
alken telescopic dilator system? Q: Sir, How many times have you visited India so far A: That time we were doing PCNLs in multiple stages. I & which tourist's places have you seen? presented data of 15 cases in German & A: This is my second visit to India, European meetings. Although it was previous was last year. Last time appreciated well, I was all the time after completing course in thinking how can we do this in 1 Nadiad, I went to Delhi, stage. Then I thought of a Agra & Hyderabad. This Tribute to Indian Urologists design of dilators. One of my time from here, I am friend also had designed it Peter Alken said during his interview with press planning to visit Lucknow, differently rolling & “ Although I invented Kanpur, & coimbtore. unscrewing type. That time procedure of PCNL, I was in Mainz. Once Storz Indian Urologists have perfected it” Q: What was your engineer had come to impression about India Mainz. In a coffee shop both of before & what is it now? us showed our designs to him. He A: Well, I started reading about India selected mine & said I can make this. A last year & only then I realized vastness of the month later, I had first telescopic dilator in my country. I feel I can spend rest of my life & still I won't hand. Since then, till today the design has remained finish exploring India. It is amazing. If you ask me same. academically, I visited few centers of excellence. I was very much impressed with the quality of work done here. Q: Any other instruments have you designed? I was amazed to see complexity of cases & results that A: Yes. I designed needle, sheath. Then I made minor you are achieving. The academic discussion was of changes in lot of existing instruments. The funny thing is, highest order. Overall I am quite impressed. I never gave my name to the dilators, needle or sheath. But some how it became famous as Alken dilators,
needle & sheath. It is quite exceptional that some Now I travel a lot & attend lot of conferences. Interestingly now- a days, I have started writing lot many instrument gets your name & I was lucky in that sense. scientific papers again. Because I read a lot, I get some Q: What is the future of stone disease? Have we new ideas & then I tell storz to attend to. I have joined reached the peak or which areas you expect some many associations in Europe & outside mainly to see how we can help other countries outside Europe. I have advances? A: Well, advances will continue to occur. Our brain has designed a module for teaching urology, which is liked by less power of imagination than what future reality would AUA as well as BAUS. So I am working on it. After my be. Instruments are becoming smaller & better. Chip on retirement attending diff conferences like AUA or EUA is tip technology will come in much bigger way. There could fun. I can attend the sessions of my interest. Previously be smart laser fibers which will fire only when in contact as departmental head, I had to attend many sessions not with stone & not to mucosa. There could be some of my interest at all. So I am quite busy now than before. magnetic forces, which can move stones from outside. So we don't have to use flex nephroscope to go in diff Q: How did you come to medicine? calyces. There could be small machine, which you leave A: My father was famous urologist. He told me to take in kidney. It will laze all stones & then will be passed in medicine & urology. I followed his advice. But it was not simple. That time we had to do 6 yrs of gen surgery urine. So there could be anything in future. before going to urology. Of course now things are different. Q: What are your hobbies? A: I am very much fond of collecting mushrooms. I am specialist in that. I go to forest & get diff kinds of Q: What is your advise to Urologists in India mushrooms to eat. I like sailing, reading, classical music A: Well I have seen the work you do. It is good. Believe in yourself. I saw lot of people asking AUA or EUA & little bit of pop music as well. guidelines for urolithiasis. The kind of stones you are getting, kind of socio-economic background you are Q: How do you spend your free time? A: I retired last year & I thought I would get lot of free time. working in, is different than western world. You form your But unfortunately it is not so. In my free time, I read & own guidelines & work accordingly. If your goal is to make pt better you will never fail. spend time with my family & children. It is good time. On that wonderful note, I thank you very much for sparing Q: What are your future plans? A: Now I am consultant for few companies like Storz. time for me. It was wonderful talking to you!
Laser in Urology : Dr Rajesh Kukreja History of the Procedure
This creates a plasma bubble that swiftly expands and acts like a sonic boom to disrupt the stone along stress Laser is an acronym that stands for light lines. amplification by the stimulated emission of radiation. Albert Einstein proposed the The photochemical effect refers to the selective concept of stimulated emission of activation of a specific drug or molecule, which may be radiation in 1917. Not until 1960, however, administered systemically but is taken up in selected was this theory put to use by T.H. Maimen tissues. By activation of the molecule or drug by a to produce the first visible light laser. He used a synthetic specific wavelength of light, the molecule is transformed ruby crystal with silver-coated ends surrounded by a into a toxic compound(s), often involving oxygen-free flash tube to produce light energy. In 1966, Parsons, radicals that can cause cellular death through using a similar ruby laser in a pulsed mode, was the first destruction of DNA crosslinks. This is a novel approach urologist to experiment with laser light in canine to destroying superficial skin or mucosal malignant and bladders. Mulvany attempted to fragment urinary calculi premalignant lesions. 2 years later, again using the ruby laser. Finally, the tissue-welding effect is derived by focusing Types of lasers light of a particular wavelength to induce collagen crosslinking. By adding proteinaceous materials (eg, 50% A. Different lasing mediums (which can be solid, liquid, or human albumin, also known as tissue solder) directly to gas) emit photons in different wavelengths of the EM the tissue edges to be welded or a chromophore that spectrum. This is at least partly responsible for the absorbs at the laser's wavelength, increased tensile unique characteristics of a particular laser. strength and decreased peripheral destruction can be 1.Solid-state laser is a laser that uses a gain achieved. medium that is a solid, rather than a liquid such as in dye lasers or a gas as in gas lasers. Generally, the Lasers in Urology active medium of a solid-state laser consists of a glass or crystalline host material to which is added a Neodymium:yttrium-aluminum-garnet laser dopant such as neodymium, chromium, erbium, or other ions. Of these, probably the most common type Studies in 1961 showed neodymium produced is neodymium-doped YAG. stimulated emissions. The ion (Nd3+) was then used to 2.Dye laser is a laser which uses an organic dye as dope many different crystals. The Y3 Al5 O12 crystal the lasing medium, usually as a liquid solution. affectionately known as YAG is used commonly today Compared to gases and most solid state lasing because of its efficiency, optical quality, and high thermal media, a dye can usually be used for a much wider conductivity, which permits high rates of repetition. range of wavelengths. 3.Gas laser is a laser in which an electric current is The Nd:YAG laser emits a beam at 1064 nm (near discharged through a gas to produce light. The first infrared) and can be delivered in a continuous, pulsed, gas laser, the Helium-neon, was co-invented by or Q-switched mode. The 1064-nm wavelength allows Iranian physicist Ali Javan and American physicist for a relatively deep penetration of as much as 10 mm William R. Bennett, Jr. in 1960. because this frequency is outside the absorption peaks B. Other characteristics that affect laser performance of both hemoglobin and water. It has good hemostatic include the power output and the mode of emission (eg, (coagulates blood vessels as much as 5 mm in continuous wave, pulsed, or Q-switched). diameter) and cutting properties and is suitable for lithotripsy when Q-switched. The biophysics of laser-tissue interactions An optical fiber is used for delivery, which may be passed Surgeons currently using lasers seek 4 different through all types of endoscopes. A sapphire or crystal effectsthermal, mechanical, photochemical, and tissue- tip, which decreases backscatter and allows for precise welding effects (which is actually mediated through cutting using a direct touch technique, may also be used thermal energy). The most common utilization is the at the end of an optical fiber. thermal effect, whereby light energy is absorbed and transformed into heat. This results in the denaturation of The frequency-doubled, double-pulse Nd:YAG proteins at 42-65°C, the shrinkage of arteries and veins (FREDDY) laser is a short-pulsed, double-frequency at 70°C, and cellular dehydration at 100°C. Once water solid-state laser with wavelengths of 532 and 1064 nm. It has completely evaporated from tissue, the temperature is a low-power, low-cost laser developed for rapidly rises, carbonization then occurs at 250°C, and, intracorporeal lithotripsy that has been a subject of finally, vaporization occurs at 300°C. recent investigation. Although the FREDDY laser is effective for lithotripsy, it is does not have a soft-tissue The mechanical effect results, for example, when a very application. high power density is directed at a urinary calculus and a column of electrons is freed rapidly at the stone surface.
Potassium-titanyl phosphate crystal laser
At higher repetition rates, it may also be used for incisions or to enucleate prostate adenomas down to the capsule. The Ho:YAG is ideally suited for this task because it creates precise incisions, cuts by vaporizing tissue with adequate hemostasis, and leaves minimal collateral damage.
This laser, also known as a potassium-titanyl phosphate (KTP) laser, yields a green visible light beam of 532 nm by passing an Nd:YAG-produced beam (1064 nm) through a KTP crystal that doubles its frequency (thus, halves its wavelength). This light penetrates less than Nd:YAG because of its shorter wavelength and its Summary of laser types and current clinical absorption by hemoglobin. It is used for incisions, applications resection, and ablation and can be passed through an lFor soft-tissue incisions (eg, urethral strictures, optical fiber and thus through endoscopic instruments. posterior urethral valves, endopyelotomy, bladder neck One disadvantage of KTP laser energy is that tissue contractures), use Ho:YAG, Nd:YAG, or KTP. carbonization can be observed, rather than a true lFor resection and ablation (eg, benign prostatic ablative effect. hyperplasia [BPH], TCC, penile carcinoma, bladder and skin hemangiomata), use Nd:YAG, Ho:YAG, In BPH, vaporization occurs when greater laser energy KTP:YAG. is focused (increased power density) and tissue lFor lithotripsy (renal pelvis, ureter, and bladder stones), temperatures reach as high as 300째C. This causes use Ho:YAG, FREDDY, pulsed dye, or alexandrite. tissue water to vaporize and results in an instantaneous lFor tissue welding (eg, vasovasotomy; urethral debulking of prostatic tissue. The high-power (80-W) reconstruction for hypospadias, strictures, diverticula, potassium-titanyl phosphate laser (KTP, or Greenlight) is or fistulas; pyeloplasty, bladder augmentation, and commonly used for its vaporization effects on prostate continent urinary diversion), use diode, KTP, Nd:YAG, tissue. This procedure is associated with significantly or Co2. less bleeding and fluid absorption than standard lFor hair removal (perineal skin for local urethral grafts): transurethral prostate resection. Because of this, the ruby, alexandrite, or Nd:YAG. KTP laser is safely used in seriously ill patients or those receiving oral anticoagulants. Drawbacks to the KTP Upcoming technology procedure compared with traditional TURP include the lack of tissue obtained for postoperative pathological The erbium:yttrium-aluminum-garnet (Er:YAG) laser analysis and the inability to diagnose and unroof has been studied for urologic application. Studies have concomitant prostatic abscesses. suggested that the Er:YAG laser may be superior to the Ho:YAG laser for precise ablation of strictures with Holmium:yttrium-aluminum-garnet laser minimal peripheral thermal damage and for more efficient laser lithotripsy. The Er:YAG laser cuts urethral Holmium:YAG (Ho:YAG) consists of the rare earth and ureteral tissues more precisely than the Ho:YAG element holmium doped in a YAG crystal that emits a laser and produces less peripheral thermal damage. beam of 2150 nm. This laser energy is delivered most The Er:YAG laser used with a sapphire fiber was also commonly in a pulsatile manner, using a found to be more efficient at calcium oxalate stone thermomechanical mechanism of action. It superheats lithotripsy than the Ho:YAG laser. A current drawback of water, which heavily absorbs light energy at this the Er:YAG laser is the extremely high cost of the wavelength. This creates a vaporization bubble at the tip sapphire optical laser fibers. of a lowwater density quartz or silica fiber used for delivery. This vapor bubble expands rapidly and The thulium:YAG laser has recently been investigated in destabilizes the molecules it contacts. This bubble an attempt to improve on some of the shortcomings of actually destabilizes stones, creating fine dust and small the Ho:YAG laser. This new laser more closely matches fragments. With a pulse duration of 100-300 the water absorption peak in soft tissue to minimize microseconds and a power range of 3-20 W, the cavitary collateral tissue damage. It has also been studied as a effects produced allow for segmental resection of all new endoscopic lithotrite, with promising initial results. stones, regardless of their composition. Accurate fiber Clinical experience with this laser is limited and reflects contact against a calculus is the primary safety factor. technical issues with the fiber delivery systems. Advantages of Ho:YAG include its minimal fragment migration and retrograde propulsion when low settings are used, its ability to fragment all stones regardless of composition or size, and its ability to deliver higher energy settings even through the smallest of delivery fibers. The absorption depth in tissue is 1-2 mm, as long as it is used in a water-based medium. This specific light energy provides good hemostasis when used in a pulsed mode of 250 ms duration and at low pulse repetition rate.
Laser Economics Cost remains the biggest challenge for the private urologist against usage of laser in endourology practise. The 20 to 30 Watt Lasers of companies such as Lisa laser (Sphinx 30), Lumenis (Versa Pulse Powersuite 20 Watt), Dornier range from appx Rs 25 to 32 lacs. The 80 Watt lasers (Lisa Shinx 80, Lumenis) range to appx Rs 70 to 80 lacs.
Water and We - Dr. Sunil Joshi Water Water is clear, colourless, nearly odorless and tasteless liquid, H2O, the most widely used of all solvents and essential for plants, animals and human life. Water on Earth ¾ of earth surface is covered with the water. 97% of water is in the ocean. Only 3% water is potable. Out of 3% water ¾ portion is on the poles in the form of snow & ice 90 % of remaining potable water is in the underground. Rest of potable water is available through rivers or lakes. Water in Human Body Human body contains 65 -70% of water of his/her body weight, new born has 80% of water of his body weight. Blood 80%, Heart 75%, Muscles 75%, Lungs 86%, Bones 25%, Liver 86%, Kidney 83% etc. Out of total body fluid ²/3 (40% of body wt.) is in intracellular fluid (ICF). Cytoplasm contains 70 to 90 % of water. ¹/3 (20% of body wt.) is in extra cellular fluid (ECF). ¾ interstitial fluid. Oral or IV fluid intake and Urine output are important measurable parameters of body fluid balance. To determine daily fluid requirement we need to know insensible fluid input and loss Insensible fluid input = 300 ml of water due to oxidation Insensible fluid loss = 500 ml through skin, 400 ml through lung, 100 ml through stool Fluid loss fluid input = 1000- 300 ml = 700 ml So normal daily insensible fluid loss is 700 ml. Higher amount of water is lost during exercise, abnormal perspiration, pyrexia, burns & surgery. In normal person daily fluid requirement is sum of urine output & insensible fluid loss. In normal person daily insensible loss is 700 ml. So daily fluid requirement = Urine output + 700 ml. Water is important for lAll biochemical reactions of the body lExcretory system lMoist and shining skin lStrengthening the muscles lJoint Movements lTo maintain body temperature etc. Human body needs 2 3 liters of water per day. Source of Water - Well, Bore well, River & Lake Impurities in Water There are three types of impurities in water Physical (dirt or suspended particles) Bacteriological (microorganisms) Chemical - Partly or totally dissolved solids (minerals)
Hardness of Water Soap cannot form foams Temporary : Caused by dissolved Carbonates of Ca, Mg, Heavy metals & Iron Permanent : Caused by dissolved Chlorides & Sulfates of Ca, Mg, Iron & Heavy metals 0- 50 ppm - Soft 50-100 ppm - Moderately Soft 100 150 ppm - Slightly Hard 150 200 ppm - Moderately Hard 200 - 250 ppm - Hard 250 ppm - Very hard PPM = part per million Softening of Water Lime Soda Treatment, Zeolite Process, Ion Exchange Process, Sedimentation, Coagulation, Sand Filters, Electro dialysis, Distillation, Ultra Filtration, Nano filtration, Reverse Osmosis. Water Softener : all cations are removed and Hydrogen ions are released : out let water is acidic : water is passed through Anion bed : anions are removed Acid converted to water. Should be done Up to 20,000 population 20,001 to 50,000 50,001 to 1,00,000 1,00,000
- Every month - Two weeks - Four days - one day
Bacteriological Contamination Salmonella Typhae, Shigella, E.Coli, V.Cholerae, Y.Entercoitica, Camphyobacter Fetus, Pseudomonas, Flavobacterium, Actinobacter, Klebsiella, S.Faecalis, S.Faecium, Durans, S.Bovis, S.Avium, C.Welchii, S.Paratyphi, Coli form micro organism should not be >3 /100 ml. E coli count should be zero in any samples of 100 ml. Viruses in water l100 types of human enteric Viruses have been isolated from water lThey are all resistant to low Ph, bile, ether & chloroform lPoliovirus, Hepatitis A, Norwalk Virus, Rotavirus lEven one virus particle is enough to cause disease lIn a water, if free chlorine is present, active Virus will generally be absent. lA free Chlorine residual of 0.5 mg/l for one hour is sufficient to inactivate Virus. lChlorination can be done by Chlorine Gas, Chlorine Tablets or Bleaching powder. · Removing Impurities of Water Filtration through cloth, sedimentation, boiling, Alum, Chlorination, Slow Sand filter, Bleaching Powder, Potassium permanganate, Cartridge Filter, Softener, Activated carbon, Aquagaurd, Reverse Osmosis
Potable Water As per WHO guidelines potable water should not have > R.O. System water is passed with great pressure 500 PPM of TDS (Total Dissolved Solids). through semi permeable membrane, so unnecessary
dissolved solutes, bacteria and even Viruses are filtered. Al2O3 : ALUM = O8S0L, It is a coagulating agent for colloidal particles, Al2O3 : ALUM + water = Al (OH)3, Al (OH)3 is gelatinous and shiny particle, they are bulky, Which forms gelatinous flakes, colloidal particles adhere to this flakes and settles downwards at the bottom of water. Supernatant water is used as drinking water Methods to purify water Physical Heat, Cold, Light U.V., Filtration Chemical Oxidizing agents, Heavy metals, pH control, synthetic detergents. Biological Chlorination, Filtration Water Hardness and kidney stones. Insufficient intake of water and other liquids, i.e. permanent dehydration, even if slight, surely increases the risk for urolithiasis of all types. On the other hand, qualitative assessment shows that the content of water minerals, more precisely of magnesium and calcium, plays a less important role. Urinary stone formation is a process involving multiple factors, i.e. not only intake of liquids, but also genetic predisposition, eating habits, climatic and social conditions, gender, etc. Several studies documented that higher water hardness is associated with higher incidence of urolithiasis among the population supplied with such water; in contrast, more studies found softer water to be associated with higher risk for urolithiasis. Nevertheless, most recent epidemiological studies explain those controversial results by differences in the study designs and say that water hardness ranging between the values commonly reported for drinking water is not a significant factor in urolithiasis (Singh et al, 1993; Ripa et al, 1995; Kohri et al, 1993;Kohri et al, 1989). Any correlation between water hardness, or the drinking water calcium or 14 magnesium level, and the incidence of urolithiasis was not found in the last vast USA epidemiological study with 3270 patients (Schwartz et al, 2002). The quoted Japanese studies did not found that the water calcium or magnesium levels alone had an effect on the incidence of urolithiasis but did found that the Mg to Ca ratio had: one study reported the lower Mg to Ca ratio to be associated with a higher risk for urolithiasis regardless of type and the incidence of urolithiase to correlate with the type of geological subsoil (Kohri et al, 1989) and another study found correlation between the higher Mg to Ca ratio and higher incidence of infectious phosphate urolithiasis (Kohri et al, 1993). Many experimental studies document that higher water hardness does not pose any risk for urolithiasis (which is not true of extreme water hardness beyond the range to be considered for drinking water - see below) and confirm concordantly that intake of calcium rich water (or magnesium rich water) reduces risk for calcium oxalate urolithiasis (Rodgers, 1997; Rodgers, 1998; Caudarella et al, 1998; Marangella et al, 1996; Gutenbrunner et al, 1989; Ackermann et al, 1988; Sommariva et al, 1987). Intake of such water is associated with higher urinary
calcium elimination and at the same time with lower urinary oxalate elimination probably due to oxalate bond to calcium in the intestine with subsequent prevention of oxalate absorption and enhanced oxalate elimination through faeces. Nevertheless, these conclusions do not apply to patients after urinary stone removal. Isolated experiments suggested that intake of softer drinking water resulted in a lower rate of recurrent urolithiasis (Bellizzi et al, 1999; Coen et al, 2001; Di Silverio et al, 2000) but admitted at the same time that the results could not be generalized and depended on multiple factors, e.g. whether water was given between meals as in one of the studies above or during meals when, in contrast, harder water intake may have been associated with a lower rate of recurrences (Bellizzi et al, 1999). Genetic predispositions and eating habits may play a relevant role in this regard. High hardness (>5 mmol/l), which is not typical of drinking water, may be associated with higher risk for urinary and salivary stone formation as documented by a Russian epidemiological study (Mudryi, 1999). The author says that a long-term intake of drinking water harder than 5 mmol/l results in a higher local blood supply in the kidneys and subsequent adaptation of the filtration and resorption processes in the kidney. This is believed to be protective reaction of the human body, which may lead, if the conditions persist, to alteration of the body's regulatory system with possible subsequent development of urolithiasis and hypertension. Risk for urolithiasis was also associated with intake of water of a hardness of 10.5 mmol/l (Ca 370 mg/l) as documented by the already quoted Italian study (Coen et al, 2001). Harmful effects of hard water No evidence is available to document harm to human health from harder drinking water. Perhaps only a high magnesium content (hundreds of mg/l) coupled with a high sulphate content may cause diarrhoea. Nevertheless, such cases are rather rare; other harmful health 15 effects due to high water hardness (e.g. the effects on the eliminatory system as mentioned above) were observed in waters rich in dissolved solids (above 1000 mg/l) showing mineral levels, which are not typical of most drinking waters. In the areas of the Tula region supplied with drinking water harder than 5 mmol/l, higher incidence rates of cholelithiasis, urolithiasis, arthrosis and arthropathies as compared with those supplied with softer water were reported (Muzalevskaya et al, 1993). Another epidemiological study carried out in the Tambov region found hard water (more than 4-5 mmol/l) to be possible cause of higher incidence rates of some diseases including cancer (Golubev et al, 1994). The results of the studies concerning the relationship between water hardness and tumors are discordant, but most of them are supportive of protective effect of harder water. We need clean, natural and mineral water. If water is not provided, Provide it, If water is provided, Protect it, If water is protected, Perfect it, If water is perfected, Maintain it
Debate : Are we ready for super-specialization in urology in India ?- Yes Why we need super-specialization As I ponder on the issue of whether we are ready for super-specialization in Urology in India, my mind goes back 20 years, when I was deciding whether to stop practicing general urology and focus exclusively on Andrology. I spoke with many of my teachers and senior colleagues; most were skeptical about focusing all one's energy on such a limited field. Finally, after much soul-searching I concluded that it would worth my while to superspecialize in Andrology if I could achieve the following goals: 1. Acquire equipment, expertise and knowledge equal to the best international standards so as to provide patients with same treatment that was available at the best centers elsewhere. 2. Identify and study problems unique to our population 3. Develop new techniques and equipment, especially addressed to our needs and reality. 4. Deal with uncommon or problematic cases that the general urologist would be unable to handle. 5. Upgrade knowledge constantly so as to provide a tertiary referral service to colleagues. 6. Provide training to general urologists that would enable them to upgrade their knowledge and skills and fill lacunae in their training in andrology. 7. Provide guidance to younger urologists wishing to specialize in this area. Today, these goals seem as relevant as they were many years ago and they highlight all the reasons why we need super-specialization in medicine today. The general urologist can do an excellent job of providing general urological care. He can stay reasonably up-to-date about advances in the treatment of common problems. He can contribute to research and clinical studies. However, with the current explosion of medical knowledge it has become impossible for a single individual to be completely knowledgeable, or even fully skilled, in all areas of urology. Hence, in the interests of both - better patient care and the advancement of medical knowledge - some urologists will have to superspecialize and dedicate themselves to developing selected aspects of urology. Are we ready for super-specialization?
specialists who can provide better care for their unique problem then they would self-refer themselves. While such awareness exists in a few cities, in most places we are still at the phase of educating patients that urologists are better than general surgeons in dealing with common urinary problems. Thus, we are still far from the time when patients will seek out the super-specialist urologist. 2. Colleagues: Currently, the major source of referral for the super-specialist will have to be other urologists. Here too, the scenario is varied. There are several urologists in our country who deal with only a specialized area of interest - uro-oncology, reconstructive urology, urodynamics, andrology, etc - and are recognized by their colleagues as offering special skills and are referred patients with special problems. However, in general, most urologists are reluctant to acknowledge their super-specialized colleagues as offering something more, or better, and are reluctant to refer patients to them. Often the general urologist will try and do whatever has to be done by himself, as best as he can do it, or will tell the patient that nothing can be done. 3. Institutions: At the institutional level there must be recognition of the need, and support, for the development of super-specialists. While this is true for both teaching and private institutions, it is particularly essential for the former. In post-graduate medical institutions there must be super-specialization by the faculty if they are to provide the best training and teaching. However, there are two impediments to the development of super-specialization in institutions: [a] Excessive workload. Most public hospitals are so swamped with routine urological work that the faculty has no time to spend on developing superspecialities. [b] Reluctance to specialize. Often, the staff members like to remain in touch with all aspects of urology, perhaps with a view to future practice. What can be done to encourage superspecialization [a] At the patient level : Patient awareness is essential. If patients know about super-specialists who can deliver better care they will fuel a demand for super-specialist services. Hence, those who choose to super-specialize will have to spend some time educating the general public through articles, talks and radio shows.
There is no point in advocating super-specialization if the medical and social milieus do not support the specialist in terms of facilities, patients and remuneration. I know of many young urologists who would like to specialize in some area of urology but do not do so because they fear that they will not have enough work.
[b] At the urologist level: The general urologist has to stop viewing the super-specialist as a threat who will undermine his practice. In the interest of the patient and the growth of urology we must become open to accepting that we cannot know everything and cannot do everything. There will be special procedures Support for the super-specialist must come from three or problem cases which could be tackled better by sources: someone else and we should be willing to refer those patients to that person. If financial considerations 1. Patients: if patients recognize that there are super-
prevent such a referral an alternative would be to invite the specialist to do the case and assist him: this would benefit all. Thus, if the general urologist welcomes the specialist as a colleague who can help him in special situations he will be able to expand the scope of the medical care that he can provide, while encouraging the specialist in his work.
super-specialist and get enough referral work if he has acknowledged unique skills which cannot be easily acquired by the general urologist. However, only a few can acquire such standing. An easier option [if we can overcome our traditional inability to work together] would be a group practice in which every member identifies and develops one or two areas of special interest. All members could treat basic urology problems but would refer to each other those patients who have problems relevant to their special interest.
The onus of referral to a super-specialist lies especially on the senior urologists. They are established well enough in practice so as not to be threatened by a young super-specialist. They have enough patients. And, their opinion carries weight: if they refer patients to a superspecialist they endorse his unique skills and send a clear In Summary message of approval to other urologists and also to the family physicians who are often the key factor in deciding Super-specialization is necessary if we are to take who should treat a patient. Indian Urology to the next level of excellence, but we must acknowledge that it is not for all. Many urologists [c] At the institutional level: Teaching institutions enjoy the variety of their work. They are the key service frequently have constrained resources and limited providers to the general population. However, superfaculty. Yet, if they have a vision for their department as a specialization by some urologists, especially in the whole, then the existing faculty can be encouraged to teaching institutions, is essential if we are to continue spend part of their time developing an area of special improving the level of urological care and knowledge in interest, and new faculty can be appointed to fill in super- India. speciality areas that are lacking. Dr. Rupin Shah M.S., M.Ch. [d] In private practice: Here super-specialization can Consultant Andrologist & Microsurgeon exist in two ways - independently or as part of a group. A Lilavati & Bhatia Hospitals - Mumbai, Muljibhai Patel urologist in private practice can work as an independent Urological Hospital Nadiad
Debate : Are we ready for super-specialization in urology in India ?- No The debate on this topic is not new. Many urologists at different platforms have addressed this issue for past many years. In spite of strong proposition form many urologists, how many are practicing exclusive superspeciality in urology? Answer is â€œhardly anyâ€?! I know many strong proponents who themselves are practicing as general urologist. I don't blame them because the fact remains that we are not yet ready for superspecialization in Urology in India. Let us go to basics. Why & how this concept has come? Obviously from western world that had problems of plenty. The condition & situation in western world is completely different than ours & we need to address our problems as per requirements. If we have western mindset & if we apply western solution to our problems, result will be utter failure. Lets us go into some of the facts. Instead of going into details of whole country, I will restrict myself to our zone. We have 5 states. Total population in 5 states of west zone is 23 Crore. (As per census 2001 Govt of India) For this population we have only 317 qualified urologists (List of full members, as per latest official wzusi directory). Thus we have approx. 1 urologist for 7 lacs people. As against, USA has total population of 30 crore. & >9000 practicing urologists in America, giving ratio of 1 urologist per 33 thousand
people. Can we match this disparity? How can their problems & needs will match to ours? To take this analysis further our zone has 126 districts, of which 78 (62%) districts do not have even single qualified urologists in whole district. This is the situation in west zone imagine what will be situation in north or east zone where UP, Bihar & Bengal form bulk of population. We need large no of urologists to fill up these vacant areas. Obviously, we need urologists who will do everything & not restrict to only small superspeciality within urology. Some people object that with this analogy we don't even need urologist but need only basic surgeons. That is not true. Urology today is completely different from surgery. PCNL, URS, TURP, cystoscopy, urethroplasty â€Śetc are highly skilled procedures done only by urologists. Surgeons are not competent to do these operations & you can't deny this large population in nonmetro cities to get themselves operated by surgeons. So urology has to be promoted but not specialization within urology. It is often argued that in metro cities there is lot of scope for practicing exclusive subjects where there is concentrated pool of urologists mimicking western situation. But I am afraid that is not true. How many branches in urology are self-sufficient? There is not enough work because none of urologists are going to
refer cases to you, there is no awareness among population, & general urologists are doing equally good job. I know many pediatric urologists doing lot of TURPs (are there pediatric TURP?). There are andrologists doing nephrectomy (may be andrological indication….???), uro-oncologists doing varicocele surgery (probably of person known to him) or transplant urologist doing cyscopy VIU (may be he will land up with ESRD in future life). Laparoscopic surgeons doing AV fistula. My appeal to them is why are you restricting yourself? Whatever you are doing do it openly. Why are you wasting your talent? Utilise your skills fully don't restrict yourself. I know so many people who do PCNL, urethroplasty, laparoscopy or microscopic VEA equally well. Why to restrict talented, skillfull & gifted people's work. I am sure there are many such gifted people in our country. India needs them. India needs their all-round skills. So don't even utter to restrict only to small branch where you will feel suffocated.
irritation leading to depression. Imagine an andrologist explaining the reasons of failure of VEA all throughout his life or a person doing female urology interacting only with post menopausal obese ladies about incontinence of urine throughout his career. I think these are surest ways to become psychotic.
I am not saying that we don't need superspecialists at all. Yes time will come when we will need them. But that time is still far off. Neither we are ready nor it is advisable at this point of time to branch out to any superspecialisation in Urology. So my sincere & genuine advise to all those who are thinking of becoming superspecialists in Urology please don't do that. You need to see every color in life. Let you skills flourish without lips & boundaries, utilize your potential to full extent, understand the power that is lying within you. Master all branches of urology equally well. Crores of our countrymen are looking at you. Fulfill their hope. India needs you…..! India needs general Let's see if someone genuinely sticks to small area of urologists……!! urology, what is his fate? All the time to see only one type of pts brings lot of monotony. Human nature & Dr. Brajesh Singhal, M.S., DNB, psychology is such that it needs change. Too much Consultant Urologists monotony in life brings disinterest, frustration, and Navjeevan hospital, Gwalior, M.P.
OBITUARY Dr. Atul Anant Thakre (1965-2009) Atul Thakre, was born in educated, well mannered Thakre family as an eldest son on 24th Feb 1965. After completing his M.Ch studies from Civil Hospital Ahmedabad, He started practice in the city. But his passion for Pediatric urology and academics compelled him to leave lucrative practice as General Urologist. He had all courage and vision to pursue his goal by going for training in Pediatric Urology at Schneider Children Hospital and Long Island Jewish Hospital, New York. He also visited many countries to gather the latest and the best in Pediatric Urology. He had formal full 3 years training at Subcontinent's best tertiary care center, Prince of Wales Hospital, Hongkong under leading Pediatric Laparoscopic and Robotic Surgeon, Dr. C K Yeung. After the return, he started practice & rejoined Civil Hospital Ahmedabad. In a short span since then, he was able to make an impact on most members of USI through his efforts for academic excellence. His effective networking, communication skills and eagerness to help someone, won him many friends, not only in India, but also all over the globe. He participated in many zonal, national & international meetings as faculty. He had mastered the art of scientific writings. He has many papers and publications in prestigious Journals and reputed books to his credit. Recently, he was honored to write Review Article for European Urology Journal on Management of VUR along with best of the contributors in the field of Pediatric Urology. His untimely death has not only shocked many, but also created a vacuum as far as development of Pediatric Urology in India is concerned. May his soul rest in peace. Compiled by Dr. Ajay Bhandarkar - Vadodara. Dr. Shrenik Shah - Ahmedabad
West Zone programs
lAnnual General meeting will be held on Saturday 21st
CME in Andrology- Raipur
November 2009 at Khajuraho at 5.30 pm in Hall A. The agenda will be circulated later. Any full member One day CME was organized at Raipur Chhatisgarh on interested in including some issue in the agenda, 14 June 2009 by Urological Society of Chattisgarh in association of UISWZ. For long time it was discussed in please write to Hon.Secretary on or before 15th Oct west zone meetings that some academic activity should 2009. start in this state. With the initiative of Dr. Lalit Shah & Dr. Ajay Parashar this particular CME was arranged. lThere is vacancy of 1 council member's post to be filled Erectile dysfunction & Male infertility - diagnosis & at forthcoming AGM to be held at Khauraho. Those management was discussed in morning. Operative technique videos were shown in the afternoon. Then interested should send their application to Returning was panel discussion on common problems. Last officer President Elect Dr. Ajit Vaze on or before 31st session was myths & misconceptions which was very October 2009 on following address: 10, Meghdoot, educative. Faculty consisted of Dr. Rupin Shah, Dr. Ajit S.H.Paradkar Marg, Shivaji Park, Dadar Mumbai Saxena & Dr.Sabnis. Total delegates registered were 400028. E mail email@example.com, mobile 110. Dr. sanjiv jain, Dr. Jayant Kanaskar, Dr. Prashant Bhagwat, Dr. Nitin Goel, Dr. Mondal & Dr. Kapoor took 9821023637 extra efforts to make program successful. lUnder the leadership of Dr. Nagendra Mishra from
Operative Video Course- Pune
Ahmedabad, Indian society for IC/PCB was formed. Inaugural meeting was held at Goa on 21 June 2009. â€œVideo operative techniqueâ€? instructional course for PG Many Urologists interested in interstitial cystitis/painful students was organized at Pune under the auspices of bladder syndrome from different parts of the country USIWZ. West zone has many teaching institutes. Every attended the meeting. It I hoped that this forum makes institute may not have high workload in all subspecialties of urology hence students from that institute may have a progress & comes out with guidelines, which will help less exposure to those surgeries. With this backgound, these patients who are usually neglected by many. this unique idea was conceived & implemented by Dr. Jaydeep Date, Subodh Shivde & Bhalchandra lDr. Vikas Jain Final year resident from MPUH Nadiad, Kashyapi. This 2 days course took place at Dinanath won USI EAU sponsored traveling fellowship to attend Mangeshkar hospital's auditorium on 1&2 August. On first day ped urology & 2nd day oncology was covered. EUREP2009 at Prague Czechoslovakia. The Faculty consisted of Dr. Shyam Joshi, Harshad Punjani, selection was based on CV, MCQ test & personal Hemant Pathak, Makarand Khochikar, Hemant interview held at Hyderabad during CUE on 13th,14th Tongaonkar & Bhalu kashyapi. Students were happy to June 2009 organized by USI. see good videos & fruitful discussion on practical spects & from exam point of view. Total 48 students from diff. parts of zone attended the course. lDr. Shashikant Mishra - Junior consultant from MPUH, won 1st prize in singapore. 40 Urology certified delegates from different Asia Pacific countries
Medical Camp- Gondawale
participated in the 2nd Asia Pacific preceptorship
Free diagnostic & operative camp at Gondavale in program held at Singapore General Hospital, Satara district is being arranged by USIWZ. As president Singapore 2009 selection was based on Paper Dr. Thatte had written in his message that west zone has Presentation, CV & personal interview. Dr Shashikant to look into patient care also & offer their services to the Mishra, won the first prize. He received medal & a needy. In line of that , this camp is being organized while this newsletter is in print. All the details will be provided in bookers cheque of 250 Singaporean Dollars at this next newsletter. program.