Most Advanced Laser Lithotripsy Surgery at World Best Hospitals in India

What are Kidney Stones?

Kidney stones are also known as calculi (plural), or calculus (singular). When it is in the kidney, it is a renal calculus. The tube draining the kidney to the bladder is the ureter, and a stone in the ureter is a urethral calculus. Passing a stone is usually very painful. However, many patients can pass a stone with only a "muscle ache" sensation in the back, and they may not be aware the pain was from a stone until it "pops out."

What are the Symptoms of Kidney Stone?

A kidney stone may or may not cause signs and symptoms until it has moved into the ureter — the tube connecting the kidney and bladder. At that point, these signs and symptoms may occur:

• Severe pain in the side and back, below the ribs

• Pain that spreads to the lower abdomen and groin

• Pain on urination

• Pink, red or brown urine

• Nausea and vomiting

• Persistent urge to urinate

• Fever and chills if an infection is present

Kidney Stones removal Laser Lithotripsy Surgery in India

Laser lithotripsy

Laser lithotripsy is a procedure to treat kidney stones. It uses a laser to break the stones into very small pieces. These pieces can be removed during the procedure. Or they may pass out of the body in the urine. You may be awake for the procedure. Or you may have medicine to make you sleep. Either way, you will not feel pain. The doctor may use an X-ray to find the stone.

First, the doctor puts a thin viewing scope with small tools, a camera, and a laser into your urethra. The urethra is the tube that carries urine from your bladder to the outside of your body. Then the doctor moves the scope and tools through your urethra and bladder into your ureter. Ureters are the tubes that carry urine from your kidneys to your bladder. If needed, your doctor moves the scope into your kidney.

If the stone is large or is in your kidney, your doctor may need to make a small cut (incision) in your back and put a hollow tube into your kidney. In this case, the doctor uses the laser to break up the stone. Then he or she removes the pieces of the stone through the hollow tube.

Your doctor may also place a small, flexible tube inside one of your ureters. This tube is called a stent. It helps the pieces of the stone pass through your body. If you get a stent, your doctor will usually remove it in a few weeks.Most people are able to go home the same day of the procedure.

Advantages for Laser Lithotripsy

• Non-invasive, does not require surgery

• Immediate relief of symptoms

• No blood loss

• Faster recovery and shorter hospital stay

• Lesser chances of infection

Most Advanced Male Urinary Incontinence Treatment at World Best Hospitals in India

What is urinary incontinence in men?

Urinary incontinence is the accidental leaking of urine. It's not a disease. It's a symptom of a problem with a man's urinary tract . Urine is made by the kidneys and stored in a sac made of muscle, called the urinary bladder . A tube called the urethra leads from the bladder through the prostate and penis to the outside of the body. Around this tube is a ring of muscles called the urinary sphincter. As the bladder fills with urine, nerve signals tell the sphincter to stay squeezed shut while the bladder stays relaxed. The nerves and muscles work together to prevent urine from leaking out of the body.

When you have to urinate, the nerve signals tell the muscles in the walls of the bladder to squeeze. This forces urine out of the bladder and into the urethra. At the same time the bladder squeezes, the urethra relaxes. This allows urine to pass through the urethra and out of the body.

Incontinence can happen for many reasons:

• If your bladder squeezes at the wrong time, or if it squeezes too hard, urine may leak out.

• If the muscles around the urethra are damaged or weak, urine can leak out even if you don't have a problem with your bladder squeezing at the wrong time.

• If your bladder doesn't empty when it should, you are left with too much urine in the bladder. If the bladder gets too full, urine will leak out when you don't want it to.

• If something is blocking your urethra, urine can build up in the bladder. This can cause leaking.

Urinary incontinence happens more often in older men than in young men. But it's not just a normal part of aging.

What are the types and symptoms of urinary incontinence?

Urinary incontinence can be short-term or long-lasting (chronic). Short-term incontinence is often caused by other health problems or treatments. This topic is about the different types of chronic urinary incontinence:

• Stress incontinence means that you leak urine when you sneeze, cough, laugh, lift something, change position, or do something that puts stress or strain on your bladder.

• Urge incontinence is an urge to urinate that's so strong that you can't make it to the toilet in time. It also happens when your bladder squeezes when it shouldn't. This can happen even when you have only a small amount of urine in your bladder. Overactive bladder is a kind of urge incontinence. But not everyone with an overactive bladder leaks urine.

• Overflow incontinence means that you have the urge to urinate, but you can release only a small amount. Since your bladder doesn't empty as it should, it then leaks urine later.

• Total incontinence means that you are always leaking urine. It happens when the sphincter muscle no longer works.

• Functional incontinence means that you can't make it to the bathroom in time to urinate. This is usually because something got in your way or you were not able to walk there on your own.

What causes urinary incontinence in men?

Different types of incontinence have different causes.

• Stress incontinence can happen when the prostate gland is removed. If there has been damage to the nerves or to the sphincter, the lower part of the bladder may not have enough support. Keeping urine in the bladder is then up to the sphincter alone.

• Urge incontinence is caused by bladder muscles that squeeze so hard that the sphincter can't hold back the urine. This causes a very strong urge to urinate.

• Overflow incontinence can be caused by something blocking the urethra, which leads to urine building up in the bladder. This is often caused by an enlarged prostate gland or a narrow urethra. It may also happen because of weak bladder muscles.

Kidney Stones removal Laser Lithotripsy Surgery in India

Urinary inconsistency condition in male can be diagnosed using several methods.

• Digital rectal examination is done to check for the enlargement of the prostate.

• Other method is abdominal ultrasonography and pelvic ultrasonography, which can identify the presence of external factors that cause the compression of the bladder.

• Urodynamics is another method for identifying the incontinence of the stress.

Apart from these diagnostic methods, a dairy has to be maintained by the candidate to count how many times one has to go to washroom for relief. It helps as an indicator of incontinence

Treatment for Male Urinary Incontinence in India

The urinary incontinence can be cured in different methods. The selection of the method and time needed for the treatment varies from one candidate to the other.

Behavioral Modification

Behavioral modification involves sufficient training for bladder and timed voiding. It gives the training for the intake of the fluid, before going to bed and before going to out for parties or car trip, etc. Such training helps avoiding the accidents, while sleeping or while being outside. Timed voiding also involves the training for emptying bladder in regular intervals. The behavioral modification is effective for the candidates suffering from the mechanical bladder compression and also an overflow incontinence.

Medications

Different medicine is given for different purposes. Certain medicine is given to relax the bladder and its surrounding muscles so that full emptying is allowed. It is done usually with alpha blockers. Some other medicine can be used for the reduction of the hormone levels so that the prostate enlargement of the prostate also can be reduced. The mechanical pressure over the bladder is reduced, easing the flow of the urine

Kegal Exercise

Kegal exercise is the strengthening of the floor muscles of the pelvic. The exercise can tighten the sphincter muscles and makes the outlet of the bladder to be closed, while performing strenuous activities. To perform this exercise, pull the pelvic muscle and continue to hold until, counting 3. Relax after counting 3. Repeat the same exercise for 3 sets and repeat 10 times. However, we should not overdo it. Kegal exercise is possible with biofeedback. It helps relieving from the stress incontinence.

Surgery

There are surgeries conducted for severe conditions of male urinary incontinence.

Artificial Sphineter:

Urinary leakage in the male candidates can be treated with the artificial sphineter. This device is an implanted device helps keeping the urethra be closed, until the candidate gets ready for urination. The artificial sphineter device is helpful for the urinary incontinence that is caused from nerve damage interfering the function of the sphincter muscle or weakened muscle function. If the inconsistency is because of the uncontrolled bladder contractions, it does not solve the problem.

Artificial sphineter surgery is performed with spinal or general anaesthesia. The device consists of three parts, a cuff, a small balloon and a pump. The cuff is fit around the urethra, the balloon acts as a reservoir, which is kept in the abdomen and the pump is kept in the scrotum. When the cuff is filled with the water, it is fit around the urethra tightly and prevents the leakage of the urine. Before the urination, the pump has to be squeezed with the finger so that the cuff is deflated and the liquid starts moving the balloon reservoir. Then the urine starts flowing the urethra. After the bladder is made empty, the cuff will be refilled in the following 2 to 5 minutes, automatically so that the urethra will again be tightly closed.

Urinary Diversion

Urinary diversion surgery is considered if the function of the bladder is lost because of the damage of the nerve or the bladder has to be removed. The surgery provides a urinary diversion. During the surgery, a reservoir is created after removing a small intestine piece and the ureter is directed to this reservoir. A stoma is also created as an opening for the lower abdomen so that the urine can be drained towards the bag through a catheter.

Male Sling

Male sling surgery procedure provides the support by wrapping a strip over the urethra. The ends of the strip are then attached to pelvic bone ends. The sling continues to keep the pressure over the urethra until the urine is released consciously by the candidate.

Most Advanced Laparoscopic Varicocelectomy at World Best Hospitals in India

A varicocele is an enlarged or dilated group of veins in the scrotum (the sac that holds the testicles). Varicoceles are located along the vas deferens, a blood vessel-rich cord that connects the epididymis, which is the area where sperm are stored, to the prostate gland, a walnut-shaped gland below the bladder that supplies part of a man's seminal fluid. Varicoceles occur when scrotal vein valves malfunction and blood pools, causing the veins to become varicose (swollen). In most men the resulting varicocele is on the left side of the scrotum.

Varicoceles are serious because they can cause infertility. Approximately 40 percent of all men evaluated for primary infertility (meaning they are unable to father a child) have a varicocele; 80 percent of all men with secondary infertility (meaning they have fathered at least one child, but are not currently able to do so) have a varicocele. Despite this fact, physicians aren't entirely certain why varicoceles cause infertility. One theory is that increased blood in the veins because of varicoceles increases the temperature of the scrotal environment, which in turn raises the temperature of the testicles so that sperm production decreases. This sperm damage can occur in both testicles even if a varicocele is on one side of the scrotum because the varicocele transfers blood to the whole scrotum and both testicles.

Varicoceles usually develop slowly during adolescence when the testes grow dramatically and more blood flows to them, which may pool on return to the heart if a vein valve malfunctions. Approximately 16 percent of adolescent boys have a varicocele, a percentage that is repeated among adult men.

What are the signs of varicocele?

In some men, varicocele does not cause any symptoms. If the sperm number and quality are normal treatment may not be required in such cases. In some however, varicocele may cause important problems including infertility. The most common symptoms of varicocele are as follows:

1. Pain: In patients with varicocele, pain may occur because of the increased blood pressure in the veins around the testicle.

2. Infertility: The blood accumulated in the testicular veins may increase the temperature in the testicle. This may decrease the sperm count and mobility and cause sperm deformation by time. In one study, about 40% of the infertile men were found to have varicocele. In 50-70% of such cases, correction of the varicocele with embolization or surgery may result in improvement of sperm parameters.

3. Atrophy: In varicocele, retention of the deoxygenated venous blood in the testicular veins may impair the blood circulation and cause testicular atrophy (shrinkage). If the patient is diagnosed at an early stage and treated properly, the testicle may regrow and reach its normal size.

4. Bad appearance: Some varicoceles may be large enough to be readily seen when the patient is standing. This may disturb some patients and cause psycological problems.

5. Leg varicosities: In some patients, varicocele may be accompanied by leg varicosities. Likewise, in patients with leg varicosities a varicocele may be detected just by coincidence. In such patients, both the varicocele and leg varicosities may be caused by the insufficiency of the main testicular vein, and the occlusion of this vein may not only treat the varicocele but also be beneficial for the leg varicosities.

What are the causes of veicoceles?

The valves in the veins that go along the spermatic cord do not work properly, a similar process as varicose veins in the legs. A defect in the valves leads to a backflow of blood into the pampiniform plexus, raising pressure there and causing the veins to dilate, and eventually damaging testicular tissue. Most varicoceles occur on the left side, where the left-testicular vein is.

How is a varicocele diagnosed?

It is best to catch a varicocele before it can cause major problems, such as infertility. Self-exam of the scrotum is the best way to diagnose a varicocele early. A varicocele can feel like a "bag of worms", and is usually found in the left testicle. The majority of varicoceles are detected by a doctor during a health checkup.

Treatment Options for Varicocelectomy in India

Laparoscopic varicocelectomy

Laparoscopic varicocelectomy is one of three main treatment options for varicoceles. The other two options are varicocele embolization (non-invasive) and traditional varicocelectomy (open surgery). Laparoscopic varicocele surgery is very similar to open surgery but is less invasive. It is a relatively new procedure often used as an alternative to testicular varicocele surgery with varicolectomy. Men with varicoceles associated with significant pain or those who have fertility problems often seek treatment.

Laparoscopic varicocelectomy is performed by surgeons who specialize in urologic surgery. The patient is put under general anesthesia while three surgical cuts, each approximately 5 millimeters in length, are made in the patient’s abdomen. Using tools inserted though these small incisions, including a tool to magnify the area, the surgeon can sever the enlarged veins from the healthy ones. Then veins that direct blood into an already enlarged varicocele can be tied off so that the varicocele will eventually disappear. During a traditional varicocelectomy, one long incision is made near the top of the penis. Advantages of laparoscopy over this type of open surgery include a lower risk of damage to vital testicular arteries and reduced post-operative pain. Patients typically need to stay home for up to three days after the procedure in order to recover. They may experience bruising and pain where incisions were made.

Open surgery to find and preserve the tiny artery that brings blood to the testes. Magnification allows identification and preservation of the testicular arteries and lymphatics, reducing the risk of complications after surgery. Microsurgery contributes to higher success rates and fewer complications.

Varicocele Embolization

Varicocele embolization is an outpatient, image-guided procedure that uses a catheter to place a tiny coil and/or drugs into the problem blood vessel to divert blood flow away from the varicocele. Unlike varicocele surgery, embolization requires no incision, stitches, or general anesthesia. Several studies have shown that embolization is just as effective as surgery and recovery is significantly less. Embolization patients can return to full activities in a day or two, but varicocele surgery patients may need to avoid strenuous activity for several days or even weeks

Advantages of laparoscopic varicocele surgery over other techniques:

1. Accurate identification of all the veins and avoiding injury to the artery and lymphatic vessels as the surgery is done under magnification during laparoscopy

2. Varicoceles from both sides of the body can be corrected at the same time without needs for further surgical incisions

3. Rapid recovery from surgery with minimal pain as the small 5mm wounds causes minimal trauma to tissue

Surgery is completed within 45 minutes, even in the case of varicoceles occurring on both sides. Patient can be discharged a few hours after surgery and return to work is within 48 to 72 hours.

World Most Advanced Radical Prostatectomy Surgery in India

Radical Prostatectomy

If you have been diagnosed with prostate cancer, your doctor will discuss different options for treatment. If your cancer is only inside the prostate gland and has not spread to surrounding tissue, your doctor may recommend a surgery called a radical prostatectomy.

In a radical prostatectomy, a surgeon removes your entire prostate gland. The prostate is a small organ that wraps around your urethra, the tube that moves urine from your bladder to your penis. The seminal vesicles (small glands that produce a liquid that is part of semen) and the vas deferens (a muscular cord that moves sperm from your testicles to your urethra) may also be removed in this surgery. The surgery is called a “radical” prostatectomy because the entire prostate gland is removed. In other prostate surgeries (i.e., a “simple” prostatectomy), only part of the gland is removed.

Different Types of Radical Prostatectomy

Open surgery

In open surgery, the surgeon uses a large incision to reach the prostate gland. Depending on the case, the incision is made either in the lower belly or in the groin between the anus and the penis. When the incision is made in the lower belly, it is called the retropubic approach. A radical prostatectomy using the retropubic approach is the most common treatment for prostate cancer. In this procedure, the surgeon may also remove lymph nodes in the area so that they can be tested for cancer.1 When the incision is made in the groin, it is called the perineal approach. The recovery time after this surgery may be shorter than with the retropubic approach. If the surgeon wants to remove lymph nodes for testing, he or she must make a separate incision. If the lymph nodes are believed to be free of cancer based on the grade of the cancer and results of the PSA test, the surgeon may skip the lymph node removal.

Laparoscopic surgery

In laparoscopic surgery, the surgeon makes several small incisions in the belly. A lighted viewing instrument called a laparoscope is inserted into one of the incisions. The surgeon uses special instruments to reach and remove the prostate through the other incisions. Men who have laparoscopic surgery tend to lose less blood during the operation and to recover faster than men who have open surgery.2 Laparoscopic prostatectomy is not yet widely available, and because it is a relatively new technique, no results from long-term follow-up after treatment are available.The main goal of either type of surgery is to remove all the cancer. Sometimes that means removing the prostate as well as the tissues around it, including a set of nerves to the penis that affect the man's ability to have an erection. Some tumors can be removed using a nerve-sparing technique, which means carefully cutting around those nerves to leave them intact. Nerve-sparing surgery sometimes preserves the man's ability to have an erection.

In laparoscopic surgery, the surgeon makes several small incisions in the belly. A lighted viewing instrument called a laparoscope is inserted into one of the incisions. The surgeon uses special instruments to reach and remove the prostate through the other incisions. Men who have laparoscopic surgery tend to lose less blood during the operation and to recover faster than men who have open surgery.2 Laparoscopic prostatectomy is not yet widely available, and because it is a relatively new technique, no results from long-term follow-up after treatment are available.The main goal of either type of surgery is to remove all the cancer. Sometimes that means removing the prostate as well as the tissues around it, including a set of nerves to the penis that affect the man's ability to have an erection. Some tumors can be removed using a nerve-sparing technique, which means carefully cutting around those nerves to leave them intact. Nerve-sparing surgery sometimes preserves the man's ability to have an erection.

Robotic-assisted radical prostatectomy

Another form of keyhole surgery is robotic-assisted surgery (robotic-assisted radical prostatectomy for RARP). A robotic-assisted device allows the surgeon to see a three dimensional picture and also to use instruments more advanced than those used for conventional laparoscopic surgery.

This method is becoming more widely available in Australia. Compared with open radical prostatectomy, robotic-assisted surgery leads to a shorter hospital stay, less blood loss, a smaller scar and faster healing.

Keyhole surgery is not suitable for all men. Also, robotic-assisted surgery is more expensive than a conventional prostatectomy, although it is now available in a number of public hospitals.

There is currently no long-term evidence to show if keyhole surgery leads to fewer side effects, such as incontinence and sexual function, than conventional prostatectomy.

Benefits of Radical Prostatectomy Surgery in India

By electing to have radical prostatectomy in India, you will be able to appreciate many benefits over having the surgery in your home country. Some of these benefits are:

• The cost of radical prostatectomy in India is a fraction of the cost in the US and other western countries. Free quotes are available online to see just how affordable it can be.

• In addition to techniques like the Da Vinci prostatectomy in India, which uses robotics, other minimally invasive procedures are available. You can choose to have a laparoscopic prostatectomy in India instead, which is a more traditional minimally invasive procedure that is carried out without the use of a machine.

• In India, you can expect to receive care from doctors who have handled a large number of cases and are very experienced.

• It’s recommended that after prostate removal surgery you begin to walk leisurely as soon as possible to help your body recover. Having your prostate removal surgery in India means you can take in a unique and beautiful culture during your recovery.

Most Advanced Male Hypospadias Treatment at World Best Hospitals in India

What is Hypospadias?

Hypospadias is a male birth defect in which the opening of the tube that carries urine from the body (urethra) develops abnormally, usually on the underside of the penis. The opening can occur anywhere from just below the end of the penis to the scrotum. In most cases, the cause of this birth defect is not fully understood. Treatment with hormones such

as progesterone during pregnancy may increase the risk of hypospadias. Certain hormonal fluctuations, such as failure of the fetal testes to produce enough testosterone or the failure of the body to respond to testosterone, increase the risk of hypospadias and other genetic problems.

Mild hypospadias usually does not cause symptoms, especially in newborns and young children. If it's more severe, a male may have problems such as spraying urine, having difficulty directing the urine stream, and having erections that are not straight. In some cases, this defect may make it impossible to urinate while standing.

Diagnosis

Hypospadias is usually diagnosed in males at birth. Upon examination, the foreskin is usually incomplete and the urethral opening is misplaced. Mild hypospadias may not be diagnosed unless removal of the foreskin (circumcision) is performed.

Some pediatricians perform ‘partial circumcisions’. In this situation the pediatrician begins the circumcision procedure, and, after exposure of the glans, identifies a hypospadias.

Due to swelling after the procedure, the consequences of a partial circumcision may look bothersome at first, but after several days or weeks the inflammation reduces and the penis appears much better over time.

Treatment for Male Hypospadias in India

Male hypospadias is treated for several reasons and is conducted in full term or healthy boys, who are in between 3 months to 18 months. However, the repair can be performed also in childhood and sometimes possibly in the adulthood. Sometimes treatment for testosterone hormone is done before the surgery in case the opening is proximal.

The surgery is done to make the penis to straight to normal position having urinary channel at the head tip ends of the penis. The surgery is performed in four steps.

• Straightening the shaft

• Creation of the urinary channel

• Positioning the opening of the urethral in the head

• Reconstruction or circumcision of the foreskin

The surgery for hypospadias repair takes 90 minutes to 3 hours. It is done usually in stages. The surgery is usually performed with spinal anesthesia or general anesthesia. Urologists perform certain tasks during the surgery. They straighten the shaft separately before the urinary channel is constructed.

Hypospadias is done in first degree, second degree or third degree. First degree is a mere cosmetic defect, in which there is hardly any effect on the function. However, in certain cases, like the direction of the stream of the urine is the exceptional condition in the first degree. If it is not corrected the following second degree or third degree will make the urination to become messy, and may create the problems related to the fertility. Sometimes it may interfere with the erections. In some countries, especially in the developed countries, most of the hypospadias repair surgery is performed during the infancy itself. Most of the time, first degree and second degree surgical repair is successful, when performed in one procedure itself. The same procedure is usually done by plastic surgeon or pediatric urologists during the year of individual’s life.

Before the surgery is performed, sometimes it would be necessary to give human chorionic gonadotropin injection or testosterone injections, in case the penis is found very small. If the hypospadias is severe, multiple procedures may be required and sometimes mucosal grafting is also required. It is important to avoid circumcision before the repair is performed.

For the hypospadias repair, many of the surgeons prefer the fresh repair to be not used immediately, by the patient. After the surgery, for the first few days it is connected with a small catheter, which directly connects to the diaper. So, the patient does not need to urinate through the fresh repair. While the catheter has been connected, antibiotics and also antispasmodics for bladder are given.

After the surgery is performed, the schedule for the follow up visits is usually dependent upon the urologists.

MyMedOpinion - World’s Most Advanced Robotic Surgery for Prostate Cancer Surgery in India

MyMedOpinion affiliated Super Specialty hospitals in India, which are amongst globally the most advanced hospitals in terms of Technology and Clinical Expertise have launched a program to help prostate patients the Robotic Prostate Surgery Service -  where a minimally invasive robot assisted radical prostatectomy technique eradicates prostate cancer with minimal post surgery complications 

The mission of “Minimally Invasive Robotic Prostate Surgery Program” is to leverage latest technology to and treat prostate  disease through small incision and great precision resulting in:

• Shorter hospital stay, Faster recovery and return to normal activities
• Less pain and scarring , Reduced blood loss and need for blood transfusion
• Reduction in the use of pain medicines, Decreased postoperative pain

Usually in conventional approach surgeons make decisions using tactile and visual cues to identify a phenomenon, which is actually microscopic which is likely to damage nerves or to leave some cancer behind.  Sometimes it is difficult for surgeons to find a precise plane between the cancer and urinary sphincter or the nerves and err on the side of cancer safety leading to incontinence or Impotence

Highly trained Indian surgeons who have worked for decades at some of the global centres of excellence now use  Advanced Robotic technique gives surgeon a sophisticated master slave robot that seamlessly translates the surgeon's movements at the computer console into precise, real-time movements of the surgical instruments inside the patient. This ensures that the Prostate is removed excellent outcomes and minimal chances of cancer left behind after the surgery. 

Prostate Surgery at MyMedOpinion affiliated hospital in India is also used for and many other advanced surgeries with excellent outcomes  like Radical prostatectomy for prostate cancer, Pyeloplasty, where  the obstruction of the pelviureteric junction is removed and renal pelvis is joined back to healthy ureter,  Partial Nephrectomy, Radical Cystectomy, Pediatric Robotic-Assisted Antireflux Surgery, Adrenalectomy , Ureteroneocystostomy, Nephroureterectomy, Ureterolysis In Retroperitoneal Fibrosis,  Ureteroureterostomy, Sacropexy, Anterior And Posterior Colpopexy 

WORLD’s LOWEST COST SURGERY PACKAGES - This most modern treatment for Prostate Cancer comes at a very attractive cost which is a fraction of the cost of similar services anywhere in the world. Robotic Prostate is made available by  MyMedOpinion  at World class hospitals in India for about   5500 US Dollars and that includes stay in a private  room where a companion can stay with the patient, surgeon fee, medicines and consumables, nursing care, patient's food and airport pick up & drop etc.