The document provides information about urodynamics testing performed at the Department of Urology, Government Royapettah Hospital and Kilpauk Medical College in Chennai. It discusses the professors and assistant professors who moderate the tests. It then describes the purpose and components of urodynamics testing, which involves a series of tests to evaluate urine storage and evacuation. The key components reviewed include uroflowmetry, measurement of post-void residual urine, cystometrogram, pressure flow studies, and videourodynamics. The document provides details on performing each test and interpreting the results.
Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
In absence of standardised criteria diagnosis of lower urinary tract dysfunction is difficult in women. Comprehensive urodynamics including pressure-flow study, urethral pressure profilometry, EMG as well as video coordination (or separately done MCUG) are often required. pelvic floor dysfunction (so called dysfunctional voiding), bladder neck obstruction and urethral stricture are differential diagnoses. initial treatment of dysfunctional voiding includes behavioural modification, pelvic floor relaxation exercises, medications, treatment of constipation. further treatment includes inj Botox into sphincter and sacral neuromodulation.
Dr Ho Siew Hong shared his experience on how to perform the ideal puncture for PCNL in a lecture to Asian urologists during the Advanced Urology Course 2008 in Singapore
The surgical treatment of an injury or defect within the urethra's walls is known as urethroplasty. The three most frequent factors leading to urethral damage that needs to be repaired are trauma, iatrogenic injury, and infections. The gold standard treatment for urethral strictures is urethroplasty, which has a lower recurrence rate than dilatations and urethrotomies. Although recurrence rates are higher for this challenging treatment group, it is likely the only effective treatment option for chronic and severe strictures.
Urethroplasty is not regarded as a small procedure, taking three to eight hours on average in the operating room. Between 20% and 30% of urethroplasty patients may benefit from the ease of going under the knife for a shorter period of time and going home the same day. On average, hospital stays last two to three days. Seven to ten days may be needed for hospitalization for more complicated surgeries.
Fewer than ten percent of patients experience significant complications after urethroplasty, while complications, particularly recurrences, are more frequent in long and complex strictures.
In absence of standardised criteria diagnosis of lower urinary tract dysfunction is difficult in women. Comprehensive urodynamics including pressure-flow study, urethral pressure profilometry, EMG as well as video coordination (or separately done MCUG) are often required. pelvic floor dysfunction (so called dysfunctional voiding), bladder neck obstruction and urethral stricture are differential diagnoses. initial treatment of dysfunctional voiding includes behavioural modification, pelvic floor relaxation exercises, medications, treatment of constipation. further treatment includes inj Botox into sphincter and sacral neuromodulation.
Hysteroscopy is a procedure used to view the inside of the uterus through a telescope-like device called a hysteroscope. Hysteroscopy offers a valuable extension to the gynecologist’s armamentarium.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. MODERATORS:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D.Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
2
3. INTRODUCTION
Dynamic study of the
transport, storage, and
evacuation of urine.
Series of tests to gain
information about urine
storage and evacuation
3
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
4. THREE IMPORTANT RULES BEFOR UDE…
1. Decide on questions to be answered
before starting a study.
2. Design the study to answer these
questions.
3. Customize the study as necessary.
4
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
5. THREE CRITICAL “GOOD URODYNAMIC PRACTICE ELEMENTS”
Have a clear indication
for, and appropriate
selection of, relevant
test measurements and
procedures.
01
Ensure precise
measurement with data
quality control and
complete
documentation.
02
Accurately analyze and
critically report results.
This includes interpreting
UDS in the context of a
patient ’ s history and
symptoms.
03
5
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
6. WHY UDE???
To diagnose the underlying cause of lower urinary tract dysfunction
To characterize the lower urinary tract dysfunction
To Formulate treatment strategies
To Improve therapeutic outcomes
To Educate patients regarding their condition
6
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
7. AIM
Reproduce the troublesome symptoms
Answer specific clinical questions
Establish a precise diagnosis
Determine the severity of the condition
Plan further investigations or therapies
Urologist’s Stethoscope 7
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
8. INDICATIONS
Optional or even unnecessary
when:
• A conservative treatment is
planned.
• In patients with uncomplicated
stress urinary incontinence.
• In patients with neurogenic
bladder at low risk of renal
complications (multiple sclerosis).
Useful when:
• The patient’s symptoms do not
correlate with objective findings
(complex symptoms).
• Prior therapies have failed.
Strongly recommended
• In females with urinary
incontinence or pelvic organ
prolapse when an invasive
procedure is planned
• In men with voiding symptoms to
assess if symptoms are due to
bladder outlet obstruction or
detrusor underactivity when
TURP is planned
• In patients with neurogenic
bladder who will require long
term urologic management to
establish a baseline
8
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
9. THINGS TO
DO BEFORE
PROCEEDING
TO UDE…
Proper Clinical History
Voiding diary
Urine culture – Exclude UTI
Physical Examination
• Local & systemic examination
• Neurological evaluation – Integrity of sacral arc
9
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
10. COMPONENTS
Uroflowmetry
Postvoid residual (PVR) urine volume
Cystometrogram
Pressure Flow studies of voiding
Electromyogram
Urethral pressure profilometry
Videourodynamics
10
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
11. UROFLOWMETRY
Simplest and often most useful
Non invasive & inexpensive
Normal - if the patient voids at least 200 mL over 15 to 20
s, and it is recorded as a smooth single curve with a
maximum flow rate greater than 20 mL/sec
Voided volume should be between 150 – 400 ml
11
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
12. TERMINOLOGY
Flow rate (Q): Volume of fluid expelled via the urethra per unit time (ml/s)
Voided volume (Vvoid): Total volume expelled via the urethra(ml)
Maximum flow rate (Qmax): Maximum measured value of the flow rate after correction for artifacts
Voiding time:Total duration of micturition (s)
Flow time:Time over which measurable flow actually occurs
Average flow rate (Qave):Voided volume divided by the flow time
Time to maximum flow: Elapsed time from onset of flow to maximum flow
12
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
14. COMPRESSIVE OBSTRUCTION
Pattern of flow seems normal til Qmax
(lower than normal) with a terminal
prolongation.
Average flow is typically lower than
normal.
BPH
14
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
16. CONSTRICTIVE OBSTRUCTION
A low Qmax is rapidly reached, and
the flow rate remains relatively
constant, giving to the curve a plateau-
shaped appearance
Urethral Stricture
16
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
18. STACCATO CURVE
Fluctuations in the flow curve due to
burst of involuntary external sphincter
contractions during voiding.
Dysfunctional voiding
18
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
19. INTERMITTENT FLOW
A flow that stops and starts several
times during voiding
Abdominal straining or neuropathic
sphincter dyssynergia
19
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
20. SUPERVOIDER / FAST BLADDER
Very high Qmax with very rapid
upstroke and downstroke.
Not diagnostic, but people (mostly
females) with detrusor overactivity or
stress urinary incontinence may have a
flow rate at the top of the range
20
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
21. ARTEFACTS
Accidental Kick
Abrupt peak recorded by the machine
during voiding.
Computerized reading Qmax - 50ml/s
Actual Qmax - 30 ml/s
21
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
22. ARTEFACTS
Voiding by straining.
Computerized reading: Qmax - 45
ml/s
Manual assessment of flow using
smooth curve: Actual Qmax - 15 ml/s
22
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
23. ARTEFACTS
Compression of the glans.
Initial peak followed a regular flow
curve.
Computerized reading, Qmax: 45 ml/s.
Manual reading, Qmax: 23 ml/s
23
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
24. ARTEFACTS
A - spurious maximum flow rate of 19
ml/s) results from squeezing the
prepuce of the penis during voiding.
B - It is eliminated revealing a true
maximum flow rate of 7.4 ml/s when
the patient stops squeezing the penis
24
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
25. POSTVOID RESIDUAL URINE
Up to 25 ml & PVR less than 10% of the total
bladder volume - normal
Between 50 and 100 ml - interpreted in the clinical
context
Values greater than 150 ml - pathological
25
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
29. PRESSURE/FLOW WORK STATION
A -Transducers on adjustable height
stand
B - Pump for bladder filling
C – Display with superimposed
screening image in videourodynamics
D - uroflowmeter
B
A
C
D
29
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
31. LAYOUT OF GRAPHICAL DISPLAY - ICS
Intra-abdominal pressure (Pabd) is
displayed at the top
Intra-vesical pressure (Pves) next
Subtracted detrusor pressure (Pdet) next
((Pdet = Pves − Pabd))
Urinary flow rate (Q) is displayed at the
bottom
Infused volume, voided volume, urethral
pressure, EMG traces and video screening
images can be displayed optionally.
Uroflowmetry 31
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
32. CATHETERS
Fluid-filled catheter with external pressure transducer
Air-charged catheter with external pressure transducer
Microtip transducer
32
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
33. FLUID FILLED CATHETERS
Records the pressure into the bladder and rectum
transmits to the external transducer through a non
compressible column of water inside the catheter and
connecting line
Low cost & disposable
Disadvantage - signal artifacts due to obstruction of
intraluminal air bubble within the catheter (damping
phenomenon). 33
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
34. AIR CHARGED CATHETERS
Filled with air and the pressure is
transmitted directly from the catheter
tip to the external transducer.
Advantage: Absence of classical
damping phenomenon and the lack of
motion artifacts created by movement
of the line.
Disadvantage: Slow response to
pressure variations and in general an
attenuation of the transmitted signal
34
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
35. SOLID STATE MICROTIP CATHETERS
Small transducer mounted on the tip that detects
pressure changes electric signal amplified and
transmitted to semiconductor converted into
pressure measurement
Advantage: Faster response in pressure change
recording and minimal motion artifacts; suitable for
ambulatory urodynamics
Disadvantages: cost, the need for sterilization, fragility
35
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
36. MICROTIP CATHETERS
Dual intra-vesical and urethral measuring microtip
catheter with transducer visible distally and further
urethral transducer visible a few centimetres more
proximal.
36
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
38. STEP 1
Step 1: EMG electrode placement
Position the electrodes on the skin around the
patient anus and on the thigh to act as the ground
lead
38
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
39. STEP 2
Step 2: Sterilizing the urethra
39
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
40. STEP 3
Step 3: Post-void residual urine
measurement
Drain the bladder with a catheter to
obtain a post-void residual urine
measurement.
40
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
41. STEP 4
Step 4: Catheter insertion into the bladder
and rectum
In female advance the catheter into the
bladder 8 – 10cm
In males, do not advance it more than 24
centimeters.
For rectal placement - to a depth of
approximately 10-15cm
Once inserted, each catheter should be
securely fixed and then connected to its
respective cable. 41
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
42. STEP 5
Step 5: Flushing
Free the catheters of air inside the channel by
flushing with infusion fluid
42
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
43. STEP 6
Step 6: Zeroing UDS machine
Atmospheric pressure taken as zero
Reference height - Superior border of the symphysis
pubis –Transducers placed at this level
The syringe and catheter connection is blocked, while
the 3-way taps of the transducers are opened to
atmospheric pressure and the “zero all” button is
pressed.
By this way, all the three lines Pves, Pabd, and Pdet
show “zero” reading. 43
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
45. POSITION OF EXTERNAL FLUID FILLED
TRANSDUCERS
Set at the level of the pubic symphysis to
allow standardization and comparison.
Increasing the height of the external
transducer lowers the measured pressure
Lowering the height increases the
measured pressure.
The position of the catheter in the organ
has no effect on the measured pressure.
45
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
46. POSITION OF MICROTIP TRANSDUCER / AIR
FILLED BALLOON
The position of the internal transducer or
balloon within the bladder alters the
measured pressure.
If the position is lower, then a higher pressure
will be measured due to the extra fluid
column above the transducer/balloon
High position will therefore have a lower
pressure
46
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
47. BASELINE PRESSURE CHECK
Pdet should show a near-zero value (<6 cmH 2 O) since
Pves and Pabd are equal and detrusor activity is absent
with
bladder empty
47
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
49. RESTING DETRUSOR PRESSURE
If the Pdet is too high (>6 cm H2O) or negative
CHECK THE POSITION OF
RECTAL ANDVESICAL
CATHETER
EXCLUDE KINKS AND LEAKS
FLUSH THE SYSTEM TO REMOVE
ANY AIR BUBBLES
Due to the pressure subtraction the Pdet should be <6 cm
H2O and ideally as close to zero as possible.
49
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
50. STEP 7
Step 7: Checking the quality of signals
Checked by asking the patient to gently
cough.
Both Pabd and Pves respond equally with
a rapid peak and rapid drop and the
detrusor line should be unaffected.
A small biphasic deflection is normal, but
any rise or fall in the detrusor pressure
during cough suggests a dampening in the
vesical or abdominal system.
50
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
51. DAMPENING EFFECT
Air bubble being compressed and ‘absorbing’ some of the pressure wave leading to
reduced transmission and a lower baseline and lower deflection on the trace.
51
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
56. TWO PHASES OF CYSTOMETRY
Storage/filling phase (also termed as FILLING CYSTOMETRY):
Commences when the pump is turned on
Ends when the patient and the urodynamacist decide that ‘permission to void’ has been
given (usually at maximum tolerated capacity).
Voiding phase (also termed asVOIDING CYSTOMETRY):
Commences when the patient and the urodynamicist decide that ‘permission to void’ has
been given, or when uncontrollable voiding begins
Ends when the patient considers that voiding has finished.
56
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
57. 4 PHASES OF CYSTOMETRIC BLADDER FUNCTION
1. Initial small increase in intravesical
pressure at the beginning of filling
2. Stable pressure that comprises the
majority of the filling phase
3. Terminal pressure rise at bladder
capacity, representing the limit of
viscoelastic expansion (often not
reached due to discomfort)
4. Voiding phase with an inconsistently
observed small increase in intravesical
pressure
57
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
58. FILL RATE
The rate of filling should have been decided prior to
beginning the procedure.
• Slow fill: <10 ml/min – a more ‘physiological’ filling rate, used in
neurogenic patients.
• Medium fill: 10–100 ml/min – the most frequent fi lling rate.
• Rapid fill: >100 ml/min – a very rapid provocative fi lling rate.
The ICS originally categorised this into three fill rates:
58
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
59. STORAGE PHASE MEASURES
BLADDER SENSATION
BLADDER COMPLIANCE
DETRUSOR FUNCTION
CYSTOMETRIC BLADDER CAPACITY
URETHRAL FUNCTION DURING STORAGE PHASE
ABDOMINAL LEAK POINT PRESSURE
DETRUSOR LEAK POINT PRESSURE
59
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
60. NORMAL SENSATION
First sensation of bladder filling – 170 – 200 mL or
~ 50% of Maximum cystometric capacity (MCC)
First desire to void ~ 250mL or ~75% of MCC
Strong desire to void ~ 400 or ~90% of MCC
60
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
61. BLADDER SENSATION
Increased – an early first sensation or an early
desire to void and/or an early strong desire to
void, which occurs at a low bladder volume and
which persists
Reduced – diminished sensation throughout
bladder filling
61
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
62. DETRUSOR
HYPERSENSITIVITY
Strong desire to void occurring at low filling volume without any
detrusor contraction. Increased sensation leads to small leakage of
62
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
63. BLADDER COMPLIANCE
Compliance (ml/cm H O) = Change in volume (Δ V) / change in detrusor pressure (ΔPdet)
Normal compliance is >30–40 ml/cm H2O.
Abnormal compliance is <30–40 ml/cm H2O.
63
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
64. BLADDER COMPLIANCE
A) Normal compliance with each 30–40
ml increase in bladder volume causing
a less than 1 cm H2O increase in
pressure.
B) Seemingly poor compliance.
C) Artefactual poor compliance due to
high fill rate
D) True poor compliance: stopping filling
does not cause a drop in pressure and
filling further at any fill rate continues
to show poor compliance.
64
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
65. BLADDER CAPACITY
Cystometric capacity
Bladder volume at the end of the storage phase
when ‘permission to void’ is given and the
investigation moves into the voiding phase.
Usually the maximum cystometric capacity
If it is not the MCC – define the reason why
fIlling was stopped
pain, large infused volume or high detrusor
end filling pressure.
Maximum cystometric capacity (MCC)
Normal sensations - volume at which the
patient feels he/she can no longer delay
micturition due to a strong desire to void.
Where there is altered or absent sensation the
MCC cannot be measured and the cystometric
capacity should instead be recorded.
Normal – 350 – 600ml
NORMAL - bladder should fill to a capacity of approximately 500 ml before there is a strong desire to void.
NO BENEFIT IN OVERFILLING ABOVE 650 -700 ML
65
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
66. DETRUSOR FUNCTION
Normal detrusor function – During the storage phase, the bladder should be
relaxed and compliant to bladder filling with little or no change in detrusor pressure.
Involuntary detrusor activity - Any detrusor activity prior to the voiding phase
66
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
67. DETRUSOR OVERACTIVITY
Involuntary detrusor contractions (IDCs) during the storage phase
Previous terminology - detrusor instability or detrusor hyper-reflexia
Types:
Phasic – having a characteristic waveform of repeated waves of DO.
Terminal – an IDC occurring at cystometric capacity, which cannot be suppressed, and
results in incontinence/voiding.
Idiopathic – when there is no defined cause for the overactivity – OVERACTIVE
BLADDER SYNDROME
Neurogenic – when there is an underlying neurological condition causing the lower
urinary tract dysfunction.
67
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
68. DETRUSOR OVERACTIVITY – THINGS TO
LOOK IN UDE
Volume at which the contraction occurred
Rise in amplitude above the baseline
Duration of the contraction
If urgency was experienced in association with the
IDC
Associated incontinence
68
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
69. HIGH PRESSURE DETRUSOR OVERACTIVITY
• Neurogenic detrusor
activity
69
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
70. PHASIC DETRUSOR OVERACTIVITY
Contraction activity with
increasingly frequent and
higher amplitude contractions
occur as the bladder
continues to be filled
70
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
72. COUGH INDUCED DETRUSOR OVERACTIVITY
• Det. OA associated
with increased intra
abdominal pressure
• Associated with
increased detrusor
pressure
• Should be differentiated
from stress urinary
incontinence when
associated with urine
leak
72
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
73. URETHRAL FUNCTION DURING STORAGE
PHASE
Normal – maintains continence in the presence of increased intraabdominal
pressure.
Incompetent – allows leakage in the absence of a detrusor contraction.
Urodynamic stress incontinence (USI) – involuntary leakage of urine during
increased intra-abdominal pressure, in the absence of a detrusor contraction
Urethral relaxation incontinence – leakage due to urethral relaxation in the
absence of raised intra-abdominal pressure or detrusor overactivity.
73
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
74. LEAK POINT PRESSURES
Abdominal leak point pressure (ALPP)
Detrusor leak point pressure (DLPP)
74
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
75. ABDOMINAL LEAK POINT PRESSURE
Intra-vesical pressure at which urine
leakage occurs due to increased
abdominal pressure in the absence of a
detrusor contraction.
Measure of the ability of the bladder neck
and the urethral sphincter mechanism to
resist increases in intra-abdominal
pressure.
Other terms -Valsalva leak point pressure
(VLPP), Cough leak point pressure
(CLPP)
ALPP (cm H2O) INFERENCE IN
INCONTINENCE
<60 Intrinsic sphincter
deficiency
60- 100 Equivocal
>100 Urethral
hypermobility
75
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
78. DETRUSOR LEAK POINT PRESSURE
Lowest detrusor pressure at which urine leakage occurs in the absence of either a
detrusor contraction or increased abdominal pressure.
Predicts upper tract dysfunction in patients with reduced bladder compliance and
poor voiding.
Measures the capacity of the bladder neck and urethral sphincter mechanism to
resist increased pressure
Detrusor leak point pressure (DLPP) >40 cm H2O: suggests upper tract
deterioration likely
78
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
80. VOIDING PHASE
Isovolumetric
contraction -
detrusor
initially
contracts
without a
change in
bladder volume
Bladder
continues to
contract -
Bladder outlet
‘opens’ and
urine begins to
be expelled
resulting in a
decrease in the
bladder volume
At the
completion of
voiding the
detrusor
relaxes and the
urethra/bladder
outlet ‘closes’
80
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
81. VOIDING PHASE MEASURES
FLOW PARAMETERS
Flow rate (Q)
Maximum flow rate (Qmax)
Voided volume
Voiding time
Flow time
Average flow rate
Time to maximum flow.
PRESSURE PARAMETERS
Pre-micturition pressure
Opening pressure
Opening time
Maximum pressure
Pressure at maximum flow
Closing pressure
Minimum voiding pressure
81
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
82. PRESSURE PARAMETERS INVOIDING
Pre-micturition pressure – the pressure recorded immediately before the initial
isovolumetric contraction. (Clinically relevant – Detrusor pre-micturition Pressure)
Opening pressure – the pressure recorded at the onset of urine flow. (clinically
relevant –Vesical opening pressure)
Opening time – the time from initial rise in detrusor pressure to onset of fl ow; this
refers to the initial isovolumetric contraction period.
Maximum pressure – the maximum value of the measured pressure, i.e. the peak
amplitude of the voiding pressure curve (Clinically relevant – Pdetmax)
82
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
83. PRESSURE PARAMETERS INVOIDING
Pressure at maximum flow (Pdet@Qmax) – the pressure recorded at
maximum measured flow rate.
Closing pressure – the pressure measured at the end of measured flow. (Clinically
relevant – Intravesical closing pressure)
Minimum voiding pressure – the minimum pressure during measurable flow
83
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
85. FLOW RATE DELAY
Flow delay is the time delay between a change in bladder pressure and the
corresponding change in measured flow rate.
Delay due to the time the urine leaves the urethral meatus until they are measured
by the flowmeter.
Usually between 0.5 and 1 second, but can be as long as 2 seconds.
Calculated for the equipment in use and a correction made when correlating flow
rates to pressure measurements
85
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
86. FLOW RATE DELAY CORRECTION
To correct for the delay the flow
rate trace should be moved to
the left by an amount equal to
the flow delay.
The measured pressures will
then correspond with the flow
rates achieved by those
pressures
The red line shows the recorded flow rate; which
must be shifted to the left (blue line) by the amount
of the delay, to determine the actual position of the
flow trace in relation to the pressure readings.
86
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
87. NORMALVALUES INVOIDING PHASE
Maximum detrusor pressure of 25–50 cm H2O
The maximum urinary flow rate should be:
over 30–35 ml/s in women
over 25 ml/s in men under 40 years
over 15 ml/s in men over 60 years.
Pves@Qmax: 15–120 cmH 2 O
Pabd@Qmax: 20–40 cmH 2 O
Pdet@Qmax: 44–107 cmH 2 O 87
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
88. DETRUSOR FUNCTION INVOIDING
NORMAL
DETRUSOR UNDERACTIVITY
ACONTRACTILE DETRUSOR
AFTER CONTRACTION
88
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
89. NORMAL DETRUSOR
Voluntary continuous detrusor contraction which leads to complete emptying of the
bladder within an acceptable time span
89
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
90. DETRUSOR
UNDERACTIVITY
Contraction of reduced
strength and/or duration,
resulting in prolonged
bladder emptying and/or
a failure to achieve
complete bladder
emptying within a normal
time span.
90
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
91. BLADDER CONTRACTILITY INDEX
BCI = Pdet Qmax + 5 Qmax
Measure of detrusor function
BCI (cmH2O) INFERENCE
>150 STRONG
CONTRACTILITY
100-150 NORMAL
<100 WEAK
CONTRACTILITY
91
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
92. ACONTRACTILE BLADDER
Does not demonstrate any contractile activity during urodynamic assessment.
CONSIDER!!! - ‘bashful’ bladder - cannot generate a detrusor contraction in the
laboratory setting
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
93. AFTER CONTRACTION
A detrusor contraction which occurs
immediately after micturition has
ended
Significance - unknown
May be associated with detrusor
overactivity
93
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
94. URETHRAL FUNCTION INVOIDING
Normal
Bladder outlet obstruction
Dysfunctional voiding
Detrusor sphincter dyssynergia
Non-relaxing urethral sphincter obstruction
94
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
97. BOO WITH DO
Pressure/flow trace in patient with
both detrusor overactivity during
filling and BOO during voiding.
This is a common pattern as many
patients have both conditions
coexisting
97
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
99. ICS PRESSURE FLOW NOMOGRAM
Used to calculate the bladder outlet
obstruction index (BOOI)
by plotting Qmax against Pdet@Qmax.
Categorize patients as
being obstructed, unobstructed or
equivocal.
Based on a number of older nomograms
(Abrams–Griffi ths, Schafer LinPURR
and URA nomograms)
Only the ICS nomogram is required in
routine clinical practice 99
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
101. DYSFUNCTIONALVOIDING
Intermittent and/or
fluctuating flow rate due
to involuntary
intermittent
contractions of the peri-
urethral striated muscle
during voiding, in
neurologically normal
patients.
101
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
102. DETRUSOR SPHINCTER
DYSSYNERGIA
Detrusor contraction concurrent with an
involuntary contraction of the urethral
and/or peri urethral striated muscle.
Intermittent opening and closure of the
urethral sphincter causing a characteristic
flow pattern and pressure changes
102
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
104. TYPES OF DSD
Characterized by a
simultaneous increase of
detrusor pressure and
external sphincter EMG
activity that reaches its
maximum at the peak of
detrusor contraction.At this
point sudden complete
external relaxation occurs
allowing urination.
01
Characterized by clonic
contractions of the
external urethral
sphincter scattered
throughout detrusor
contraction. Patients
usually void with an
interrupted stream.
02
Characterized by an
external sphincter
contraction persisting
during the entire detrusor
contraction.These
patients void with an
obstructive stream or
cannot void at all
03
104
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
106. NON-RELAXING URETHRAL SPHINCTER
Non-relaxing, obstructing urethra may result in reduced urine flow and tends to
occur in patients with a sacral or infra-sacral neurological lesion
Meningomyelocoele or radical pelvic surgery.
106
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
107. STOP TEST
During voiding in a video urodynamic
study the male patient can be asked to
stop voiding.
A - Normal - contrast is “milked back”
from the distal sphincter mechanism
proximally through the bladder neck
into the bladder.
B - Obstruction at the level of the
bladder neck - contrast will be trapped
within the prostatic urethra with intra-
vesical and detrusor pressure spike 107
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
108. STOP TEST
Isometric pressure
contraction during stop
test
The detrusor & intravesical
pressure spike during the
stop test
Thought to be a sign of
detrusor power
108
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
111. URETHRAL PRESSURE PROFILOMETRY
Measured along the length of the
entire urethra by withdrawing the
measuring catheter mechanically at a
constant speed.
The resulting profile indicates the
pressures within the urethra from the
bladder neck to the meatus
Urethral closure pressure profile:
derived by the subtraction of intra-
vesical pressure from urethral
pressure.
111
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
112. URETHRAL PRESSURE PROFILOMETRY
Maximum urethral pressure: The
maximum pressure of the measured
profile.
Maximum urethral closure pressure
(MUCP): The maximum difference
between the urethral pressure and the
intra-vesical pressure.
Functional profile length: The length
of the urethra along which the urethral
pressure exceeds intra-vesical pressure
Maximum urethral closure pressure <20 cm H2O: suggests intrinsic sphincter deficiency
112
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
113. AMBULATORY URODYNAMICS
ICS DEFINITION - “any functional test of the lower
urinary tract predominantly utilizing natural filling of the
urinary tract and reproducing subject’s normal activity.”
Study is performed over a longer period of time, usually 4
h, and allows more than one cycle of bladder filling and
voiding.
Utilizes a natural bladder filling (a standard fluid intake of
200 ml half-hourly is recommended).
Takes place outside the urodynamic laboratory.
Normal activities of daily living are reproduced more easily.
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
114. BEFORE CONCLUDING…
Read all the pressure flow measurements in a wholistic manner
No individual measures should be interpreted separately
Interpret UDE always with clinical context
Look for artefacts and deduce them
Repeat UDE whenever necessary
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DEPT OF UROLOGY, GRH AND KMC, CHENNAI.
115. Not as difficult as you
think…
Recommend UDE
whenever necessary…
115
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.