Prostate Cancer Sceening
Prostate Cancer Screening
Prostate cancer is one of the most common cancers in men. It is estimated that one out of every 9 American men will develop prostate cancer before the age of 85. The risk of developing prostate cancer greatly increases with age. It rarely occurs in men younger than 40.
Every man over the age of 40 should have a digital rectal examination (DRE) as part of his regular annual physical checkup. In addition to the DRE, it is recommended men greater than 45 have an annual physical including DRE and prostate-specific antigen blood test (PSA). For men in a high-risk category, including family history (father or brother) or if the individual is African-American, annual screenings should begin at age 40. If either digital rectal examination or the prostate-specific blood test is abnormal, further evaluation including a biopsy should be considered.
For most men, prostate cancer is a silent disease – with no pain or other warning signs telling you cancer is there – until it is advanced. But early detection – before symptoms develop – is available and saves lives.
PSA and DRE Testing
Urology Associates recommends an annual physical including a PSA & DRE after the age of 45. High-risk individuals should begin annual screenings at age 40. A PSA is a blood test and a DRE is an exam where the physician feels the prostate and evaluates for lumps or hard areas that could indicate prostate cancer.
- PSA testing is a blood test for men that assesses levels of the prostate-specific antigen, a protein that can indicate the presence of prostate cancer.
- The higher the PSA levels, the more likely a man has prostate cancer. PSA levels below 4.0 ng/mL are generally considered normal. If a PSA exam comes back high, a biopsy of cells from the prostate will be taken to confirm whether or not the patient has prostate cancer.
- Other conditions such as an inflamed prostate, can also result in high levels of PSA.
“If I hadn’t gotten the testing, I wouldn’t have caught cancer early, and I would likely have had a much greater problem,” says Bob.
An early PSA test allowed Bob Roper to live his retirement to the fullest, click here for Bob’s story.
Roughly 500,000 vasectomies are performed in the United States every year. A significant portion of these vasectomies are performed in the traditional manner, using a scalpel to cut an incision into the scrotum. It is due to this method that many men may feel weary or hesitant toward undergoing a vasectomy.
However, a less invasive, faster-recovering procedure called keyhole vasectomy provides men a safer contraceptive option. Both vasectomy methods, involve stopping the flow of sperm into semen. As the testicles produce sperm, the supply of a male’s sex cells is stored in the epididymis. Upon the anticipation of ejaculation, the vas deferens transports sperm from the epididymis to the ejaculatory ducts where it is mixed with semen. Over 97 percent of fluid that comes from ejaculation is produced by the prostate and seminal, meaning only 3 percent is sperm. Vasectomies serve to block sperm from being transported through the vas deferens, providing a highly effective birth control measure.
Traditional Vasectomy vs. No-Scalpel Vasectomy
Step 1: The scrotum is numbed with a local anesthetic by injecting a small needle into the selected area.
Step 2: Two small cuts are made in the upper section of the scrotum.
Step 3: The vas deferens are located, and partially removed through the incision points.
Step 4: The vas deferens are cut.
Step 5: The tubes are sealed by tying, cauterizing, or surgical clips.
Step 6: The vas deferens are inserted back inside the scrotum.
Step 7: The incision cuts are stitched or glued closed.
Total Procedure Time: 30 Minutes
Step 1: The scrotum is numbed with a local anesthetic by injecting a small needle into the selected area.
Step 2: The physician will feel for the vas deferens under the skin.
Step 3: Once located, the scrotal skin is stretched and the vas deferens are held in place by clamps.
Step 4: A sharp needle like tool pokes a small hole in the scrotum. The vas deferens are pulled through the hole and cut.
Step 5: The tubes are sealed by tying, cauterizing, or surgical clips.
Step 6: The vas deferens are inserted back into the scrotum.
Step 7: A band aid may be placed over the incision. No stitching or gluing is needed.
Total Procedure Time: 10 Minutes
Occasionally an additional step may be taken by the physician to further ensure no sperm reaches the ejaculatory ducts. In a process called fascial interposition, connective tissue is sewn between the vas deferens cuts. Both vasectomy methods are outpatient procedures that can be performed in a physician’s office.
Advantages of No-Scalpel Vasectomies
Since the no-scalpel vasectomy was introduced in the United States in the mid-1980s, it has become an option for male contraception, as opposed to traditional scalpel vasectomies. Due to the increased advantages, more men are deciding to have keyhole vasectomies.
- Less invasive
- Sexual activity may be resumed as soon as the patient feels comfortable
- No stitches or scarring
- 40% – 50% quicker recovery timeline
- Doesn’t negatively impact sex drive
- Less chance for bleeding complications
- Long-term contraceptive option
- Highly effective
- Reduces the risk of infection
- No scarring
- Little post-procedure pain
- Requires men to use a second source of birth control for the first 12 weeks following surgery
- A less common form of vasectomy
- Side Effects
- Short terms soreness and/or bruising
- Small chance of developing sperm granuloma
- 99.85 to 99.9% effective (Need to undergo a semen analysis 12 weeks following the procedure)
No-scalpel vasectomies are intended to be permanent, and while it can be reversed it is complex, expensive, and has lower success rates than traditional vasectomy reversals.
Want More Information On No-Scalpel Vasectomies?
Here at Urology Associates of Central Missouri, our highly skilled physicians are here to provide you with the best support, information, and care. If you are interested in knowing more or want to schedule a consultation for a no-scalpel vasectomy, please feel free to contact our office.
Penile Implant as An Option For ED
The introduction of phosphodiesterase type 5 inhibitors (Viagra™) in 1998 contributed to increased awareness and patients requesting therapy for ED. However, ED pills do not work for many men and their efficacy can weaken with time. Among the many erectile dysfunction treatment options, implantation of a penile prosthesis has been associated with high patient satisfaction rates and low mechanical failure rates. These devices are either malleable or inflatable.
A penile implant is a device that is placed into a man’s body and is designed to help him achieve an erection and experience the joys of sex again. Implants are a long-term ED treatment option that enable an erection as often and long as you wish. The implant is covered by many insurance plans. You should be able to have an orgasm with a penile implant if you were able to have one before your surgery, unless you have another medical problem that affects it.
When implanted, the penile implant is not visibly noticeable. The penis appears relaxed and normal in the flaccid state, and it is not obvious by looking at a man that he has an implant.
There are two basic types of penile implants that Coloplast offers:
Both enable men with erectile dysfunction to have a satisfactory erection for sexual intercourse and to experience the joys of sex again. You should be able to have an orgasm with a penile implant if you were able to have one before your surgery, unless you have another medical problem that affects it. Consult your physician about this. The primary difference between the two implant types is that flexible rod implants (the Genesis) produce a permanently firm penis, while the inflatable implants (the Titan) produce a controlled, more natural erection.
There are three basic types of penile implants that Boston Scientific offers:
- AMS 700™ Inflatable Penile Prosthesis
- AMS Ambicor™ Inflatable Penile Prosthesis
- Spectra™ Concealable Penile Prosthesis
Boston Scientific’s penile implants are designed to be easy to use to achieve a natural and rigid erection to put one back in control of one’s sexual intimacy. The AMS 700 LGX Penile Implant is Currently the ONLY penile implant on the market with cylinders that expand in GIRTH and LENGTH. Learn about how to live with a penile implant, including how it works, how to use it to achieve an erection and more.
To learn more about penile implants and which option is best for you, please contact our main office at 573-499-4990 and schedule a consult with Dr. Clay Mechlin.
Vasectomy is the most common form of male contraception in this country. Each year, about half a million men in the United States who want to practice reliable birth control without placing the burden on their female partners undergo this relatively simple surgical procedure.
Vasectomy is the clinical term given to the process of dividing the tubes that deliver sperm from the testes. A typical vasectomy is done on an outpatient basis. The procedure typically takes about 30 minutes and involves minimal surgery. Generally, the patient heals quickly with relatively few complications or failures and no discernible negative impact on sexual performance.
What a Vasectomy Does and Does Not Do
In a vasectomy, the physician cuts and ties off the ends of the vas deferens. This prevents sperm from mixing with the seminal fluid. Although the testes will continue to produce sperm, they can no longer pass through the vas deferens. Instead, they die and are absorbed into the body.
Because semen consists of about 95% seminal fluid, there is virtually no discernible difference in the ejaculate. Similarly, because the testes continue to produce the male hormone testosterone, which is absorbed into the bloodstream, the procedure also has no effect on a man’s sex drive.
In recent years, many physicians have adopted a new surgical technique called “no-scalpel” vasectomy. This technique often results in less swelling and pain than the traditional method. The “no-scalpel” procedure is similar to a traditional vasectomy in many respects, but it is done without incisions or stitches. Once the anesthetic takes effect, the physician makes one puncture in the scrotum with a pointed clamp. Each of the two vas deferens are cut and tied. Compared to the conventional vasectomy, the “no-scalpel” approach is slightly quicker (about 10 to 20 minutes), causes less postoperative discomfort and lower incidences of bleeding or infection.
It is important for the patient to realize that the vasectomy does not produce instant sterilization. A substantial amount of sperm still remain in the prostate and vas deferens above the portion that was removed. In most men, it takes from 10 to 14 ejaculations over the next 2 months or so before a sperm count of zero is reached. The patient typically is asked to produce a semen sample for analysis about 6 weeks after the procedure. Until then, another form of reliable birth control should be practiced. Physicians typically consider the procedure successful when the patient produces two consecutive negative sperm samples, taken 2 weeks apart.
In rare cases, patients continue to show sperm in their samples for up to a year after the procedure. This may be the result of poor sperm migration out of the vas deferens or it may indicate that the severed ends of the vas deferens have reattached themselves to one another, a condition called recanalization. The only solution to this problem is a repeat vasectomy.
Vasectomy and Prostate Cancer
In recent years, a controversy has been reported in some medical journals, suggesting that men who undergo a vasectomy may face an increased risk of prostate cancer many years later. Other studies have failed to confirm this and the research which initially suggested a connection between vasectomy and prostate cancer contained few details to explain the mechanism by which such cancer might result. At present, the hypothesis can only be said to remain unproven.
Nevertheless, as a precaution, the American Urological Association (AUA) recommends men over age 40 who have had a vasectomy more than 20 years previously should have an annual test for prostate cancer called a PSA. This is precisely the same recommendation the AUA and the American Cancer Society makes for all men age 50 to 70.
Laser Vaporization of the Prostate
New laser treatment combines the effectiveness of an invasive surgical procedure with the safety and ease of a minimally invasive treatment for an enlarged prostate.
Unlike traditional prostate surgery, laser surgery avoids cutting or scraping tissue. As a result there’s generally less blood loss — which can make laser surgery a good option for men who have blood-clotting conditions or who take blood thinners.
Laser vaporization of the prostate is one of several minimally invasive treatment options for an enlarged prostate, a condition known as benign prostatic hyperplasia (BPH). Like other minimally invasive treatments, This can offer faster recovery and symptom relief compared with traditional prostate surgery.
Laser photo vaporization of the prostate removes excess prostate tissue using patented high-power diode lasers. The laser energy quickly vaporizes and precisely removes the enlarged prostate tissue in a virtually bloodless procedure. This allows even patients on blood thinner therapy, such as aspirin or warfarin, to be treated. Furthermore, we are able to treat very large prostate glands that are not amenable to other current procedures and usually require an open surgical approach.
PVP removes excess tissue so urinary symptoms are rapidly relieved, accompanied by a dramatic improvement in natural urine flow. Most patients are released in less than 24 hours. Recovery time is short and comfortable, side effects are minimal.
What are the benefits of laser surgery?
- Immediate symptom relief.
- Urine flow improves dramatically after virtually bloodless procedure.
- Outpatient or “same day” surgery
- Patients are able to return to their ordinary daily activities in 2-3 days.
Hand-Assisted Laparoscopic Total Nephrectomy
A minimally invasive technique used to remove the entire kidney, a section of the tube leading to the bladder (ureter), the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the kidney.
Radical or total nephrectomy is the surgical removal of the kidney, the fat surrounding the kidney and the adrenal gland, which sits atop the kidney. A nephrectomy is a more involved procedure, which includes a radical nephrectomy plus removal of the entire ureter together with a cuff of bladder. This latter procedure is performed for a specific type of kidney cancer, a transitional cell carcinoma. In this type of cancer, the abnormal cells may also be present in the ureter, necessitating its removal.
A total nephrectomy is only recommended if a tumor is so large or in such a position that the entire kidney must be removed in order to deal with the tumor. In many cases, smaller tumors can be removed without sacrificing the entire kidney. These issues will be discussed with you before your surgery.
After the patient is asleep, he/she is then turned onto the side. 2-3 keyhole size incisions along with a small incision for the surgeons hand are made on the same side of the body as the kidney tumor. Long instruments are inserted through these keyhole incisions. The surgeon watches inside of the abdomen on a television monitor. The blood vessels of the kidney and the ureter (the tube that drains the kidney to the bladder) are exposed, clipped and cut, and the kidney is released off all attachments. It is then placed into a bag, and pulled out through one of the incisions. This incision is extended to approximately 3-5”, depending on the size of the kidney and tumor. After the operation, the patient will feel much less pain compare to the conventional open surgery. This is mainly due to the small incisions made, but also, no large metal retractors are needed to keep the incision open, which contributes to less pain. Blood loss is almost always minimal; therefore patients will not likely require blood transfusion. Less pain translates to earlier recovery. The patient is given regular diet by the first day after surgery, and is encouraged to get out of bed and walk. Most patients stay in the hospital for 1-2 days, and usually are back to work within one month. This is in contrast to the open procedure, which the patients typically have an incisional scar of 7”-10”, and are hospitalized for 4-5 days, with a recovery time of approximately 6-12 weeks.
Hand-Assisted Laparoscopic Partial Nephrectomy
A minimally invasive technique used to remove only the diseased or infected portion of the kidney. Once a solid renal tumor is found on kidney imaging, because of the high risk they represent a kidney cancer, surgical excision is the standard treatment. Small renal tumors can often be treated, without sacrificing the entire kidney, by removing only the tumor and a small part of the kidney. Many studies have proven that this technique, termed partial nephrectomy, has similar cure rates to removing the whole kidney, without losing significant renal function. In the past, these operations were performed through a large and painful flank or upper abdominal incision, with risk of significant bleeding routine. Also, recovery time from such an operation was lengthy and difficult. The da Vinci Robotic Partial Nephrectomy has revolutionized kidney surgery by minimizing bleeding, speeding recovery, and maximizing preservation of renal function.
After the patient is asleep, depending on the location and size of the tumor, the surgeon may need to place a plastic tube (ureteral stent) into the kidney prior to removing the tumor. The stent is inserted by using a scope through the bladder and is a short procedure which takes approximately 20 minutes. Irrigating this tube will allow the surgeon to see if there is leakage of urine after the tumor is excised from the kidney. The patient is then placed on his/her side on the operating table, and 4-5 keyhole incisions are made on the skin. Long instruments are inserted into the incisions, and the operation is performed through these keyhole incisions. The surgeon watches the inside of the abdomen on a television monitor. The kidney and tumor are exposed, and the artery and vein feeding the kidney are isolated. A clamp is placed across the kidney artery to prevent bleeding. The tumor is cut from the kidney with a rim of normal tissue. After the tumor is removed from the kidney, blue dye is injected into the stent which was previously inserted. The blue dye will allow the surgeon to see areas that need to be repaired to prevent urine leakage. The tumor defect on the kidney is closed with sutures. The clamp on the artery is then released. After the surgeon makes sure that there is no bleeding, the tumor is placed in a bag and removed from one of the incisions. A renal drain is left for 24-48 hours.
After the procedure
The patient will feel less pain compared to the open partial nephrectomy. This is, in part, due to the small keyhole incisions made; compared to an open partial nephrectomy, where a 7-10” incisional scar is made. Further, no large metal retractors for keeping the incision open are necessary, thus contributing to less pain. Less pain also means faster recovery. The patients are typically given regular diet and are walking around by the first day after surgery. Hospitalization is usually 2 days following surgery, and the patients are back to their normal activities by approximately 4 weeks following surgery.
Urethroplasty with Excision and Reanastomosis
Urethroplasty is a open surgical procedure for urethral reconstruction to treat urethral stricture. Primary anastamotic repairs involve excision of the stricture with reconnection of the healthy ends of urethra in a widened configuration.
Transurethral Ultrasound of the Prostate (TRUS)
This test is useful in guiding needle biopsy of the prostate for the diagnosing for prostate cancer. Trans-rectal ultrasonography (TRUS) is a helpful diagnostic that helps in the early detection of prostate cancer. It uses sound waves to produce an image of the prostate gland. It also allows and accurate measurement of the size of the prostate that can help guide treatment of BPH or benign (non-cancerous) enlargement of the prostate which can cause difficulty urinating. TRUS can also be a helpful tool in the evaluation of male infertility. TRUS can identify findings suggestive of a blockage of the male reproductive tract that may be correctable. Ultrasound is safe, noninvasive, and does not use ionizing radiation.
Transurethral resection of Ejaculatory Ducts
The absence of sperm from the ejaculate (azoospermia) is found in 15% of infertile men and obstruction of the ductal system is responsible for approximately 40% of cases. Obstructive azoospermia may result from epididymal, vasal, or ejaculatory duct pathology. Vasectomy is the most common cause of vasal obstruction. Severe genitourinary infections, injury during scrotal or inguinal surgery such as hernia repairs are other common causes of obstructive azoospermia. Patients with low volume of ejaculate (1.0 cc or less) and acidic semen that have been found to have an obstruction of the ejaculatory ducts confirmed with a transrectal US or seminal vesiculography and candidates for TUREDs.
Microsurgical Varicocele Repair
Varicoceles have long been identified as the most common reversible cause of male infertility. 15% of men in the general population have a clinical varicocele (large dilated testicular veins in the scrotum) but the incidence in infertile men is much higher. 19%–41% of men with primary infertility and 45%–81% of men with secondary infertility having clinical varicoceles.
Testicular Biopsy and Sperm Extraction
Diagnostic testicular biopsy with sperm extraction:
A testicular biopsy can be performed in the office under local anesthetic or with sedation in order to extract sperm for in-vitro fertilization. This male be indicated in men with a blockage of the reproductive tract who are not good candidates for reconstructive surgery or whose female partners require reproductive assistance. The sperm can also be cryopreserved at this time to be used for in-vitro fertilization at a different date.
Microsurgical testicular dissection and sperm extraction
Patients who have had a previous biopsy showing no sperm or failed biopsy with testicular extraction are candidates. Patients with high risk factors for isolated islands of sperm producing tissue likely to be missed with conventional biopsy are candidates. These include those patients with certain genetic conditions such as Kleinfelter’s syndrome or AZF-c Y-chromosome micro deletions and those with a history of chemotherapy or undescended testicles.
Study to determine the flow rate of your urine during urination (voiding). The picture above shows a normal curve with a good flow and a curve from someone with a blockage or obstruction of the urinary tract and weak flow. It is important to come to the office with a very full bladder so that the test is accurate. A blockage in a man is usually indicated by flow rates less then 12 ml/second.
A diagnostic procedure used to evaluate for prostate cancer because of abnormal PSA levels or abnormal rectal exams. An ultrasound probe is placed in the rectum and a local anesthetic is used to numb the prostate. A needle is then used to take biopsies of the prostate.
A diagnostic procedure performed in the office under local anesthetic that uses a small fiberoptic camera to inspect the inner lining of the urethral and bladder.
Bladder Ultrasound and Post Void Residual
Bladder Ultrasound and Post Void Residual (PVR) is for patients who have urinary retention problems (inability to empty the bladder completely) post-void residual measurement is a way to evaluate the amount of urine remaining in the bladder once urination (or voiding) has occurred. Post-void residual (PVR) urine volume is the volume remaining in the bladder immediately after completion of voiding.
The procedure is usually done within five to ten minutes after urination and can be done with a physical exam, an ultrasound or catheterization. If a patient has high post-void residual volume of urine left in the bladder, it could indicate a urinary tract infection, a renal deficiency or benign prostatic hyperplasia(BPH). The condition may also be caused by certain drugs or medications or by certain disorders such as multiple sclerosis, diabetes or Parkinson’s.
What to expect during the ultrasound
This study is done with an ultrasound. You will be asked to lie flat on the exam table. Gel is placed on the skin over your bladder. The ultrasound probe will be placed over this area, and a recording will be made. You will have no side effects as a result of this study, and your doctor will be able to go over the results with you immediately. It usually takes just a minute or so.
Testicular Doppler Ultrasound
Ultrasound imaging of the scrotum uses sound waves to produce pictures of a man’s testicles and surrounding tissues. It is the primary method used to help evaluate disorders of the testicles, epididymis (a tube immediately next to a testicle that collects sperm) and scrotum. Ultrasound is safe, noninvasive, and does not use ionizing radiation.
Ultrasound uses sound frequency to produce images which are viewed on a monitor. Physicians frequently use ultrasound in the office setting to view internal organs for to assess whether or not any abnormality/disease exists. Ultrasound of the scrotum is the primary method used to evaluate disorders of the testicles and the surrounding tissues.
What to expect during the Testicular Doppler Ultrasound
The patient lies on his back on an exam table. A rolled towel is placed between the patients legs to support the scrotum. The penis is lifted up onto the abdomen and covered. A gel that enhances transducer contact with the skin is placed on the scrotum and the ultrasound transducer is positioned gently onto the scrotum. As the transducer is moved over the scrotum, images are created, viewed, and interpreted by the physician. The exam takes approximately 15-30 minutes.
Penile Doppler Ultrasound
Penile ultrasound can be used to evaluate many conditions affecting the penis, including Erectile Dysfunction (ED), plaques (such as those caused by Peyronie’s disease), fibrosis, lumps, and even cancer.
What to expect during the ultrasound study
You will be lying on your back on the examining table. A penile injection will be performed to provide the penis with a medicine that causes increased inflow by vasodilating the penile arteries. Once this is accomplished at timely intervals (5 and 15 minutes), an ultrasound of the cavernosal arteries of both sides of the penis will be performed. To do the penile Doppler study, a probe is lubricated and placed on the penis.
A Doppler ultrasound is noninvasive and the test itself shouldn’t hurt. You may experience a very short, mild discomfort initially during the penile injection. Men might also feel dizzy for a few minutes. If the induced erection lasts longer than the test, the doctor might give another injection so the penis will become flaccid again. Men are usually advised not to take any erectile dysfunction medications for a day or two before the test.
Transurethral = through or across the urethra (tube through which urine exits bladder)
Incision = making a cut in
Resection = cutting away or removal (some people refer to it as a “scraping”)
Bladder Neck = the opening of the bladder where the urethra begins
This procedure is done to open up a BNC or bladder neck contracture (restricting scar tissue)at the neck of the bladder. The bladder neck is the lower part of the bladder that connects to the urethra. The muscles may be cut at one or several locations. The operation is performed through the penis using a telescope and a hot wire loop to core out the central 2/3 of the prostate, rather like coring an apple. If the prostate is too large for this method, it may have to be removed through a cut on your tummy (this only applies to 1% of patients). If only the neck of the bladder is too tight it can be released with a cut.
Conditions for which the procedure may be recommended include obstruction of the bladder neck due to benign enlargement of the prostate gland (prostatic hyperplasia) or scarring (contracture) that can occur after resection of the prostate. It can also be performed to treat a condition in which there is dysfunction of the bladder neck leading to obstruction (dyssynergia).
The most common reasons to have a bladder neck contracture are:
- a history of transurethral resection of the prostate, referred to as a TURP (prostate scraping procedure) or transurethral resection of a bladder tumor
- a history of an open prostate operation such as radical prostatectomy (removal of the prostate for cancer treatment) or simple prostatectomy (removal of the center portion of a prostate that was too large for a TURP procedure)
- a history of radiation and/or radioactive seed implantation for prostate cancer treatment
The symptoms characteristic of a bladder neck contracture are those of obstructive urination pattern. The most common symptoms are:
- Straining (need to push to begin urination)
- Hesitancy (delayed onset of urination following the urge to urinate)
- Slow or diminished force of stream
- Intermittence (urine stream that starts and stops)
- Sensation of incomplete emptying
Other symptoms that may be associated are what we call irritative symptoms and include: frequency of urination, urgency to urinate and nocturia (getting up at night to urinate).
This treatment is generally performed in the office and involves stretching of scar tissue in the urethra called a stricture. Strictures cause the urethra to be narrower than normal and can cause a blockage and difficulty emptying the bladder. The channel in the urethral is numbed with a local anesthetic and then dilated with progressively larger dilators to enlarge the urethra.
Direct Vision Internal Urethrotomy
Direct Vision Internal Urethrotomy (DVIU) is a surgery to repair a narrowed section of the urethra. This is referred to as a stricture. The urethra is the tube through which urine passes from the bladder to the outside of the body.
- A DVIU is an endoscopic procedure. This means a camera is passed through a normal opening in the body (the urethra in this case) without making an incision.
- The stricture is cut open with a knife or a laser to increase the caliber of the urethra.
- Usually a catheter or foley is left in place for 5-7 days.
- It takes at least 48 hrs for the lining of the tube to start to reform after being traumatized or cut. This is why it is advantageous to leave a catheter.
- The success rate of this procedure depends on
- location of stricture
- length of stricture
- thickness of scar
- number of prior procedures
- This procedure is preferred in patients who are too sick to undergo a major reconstructive procedure.
- It can be performed under local anesthesia with sedation.
Urethroplasty with Buccal Graft or Flap
Urethral reconstructive surgery, or urethroplasty, is the only “definitive” treatment option for urethral strictures. It is usually reserved for strictures that are severe or non-responsive to endoscopic management
There are 2 general types of urethroplasty procedures:
- Primary anastamotic repairs: Primary anastamotic repairs involve excision of the stricture with reconnection of the healthy ends of urethra in a widened configuration.
- Substitution repairs: Substitution urethroplasty involves tissue transfer techniques typically using buccal mucosa (inner cheek lining) grafts or genital skin flaps to build on to the stricture and increase its caliber
Surgery for urethral strictures, or urethroplasty, is varied and involves many different techniques. If strictures are short and in certain portions of the urethra, the area of the urethra can be surgically removed and the healthy urethra can be reconnected. If the urethral stricture is lengthy, then other tissues need to be used to reconstruct the urethra.
One common tissue used in surgery for longer strictures is the lining of the inner cheek; this is referred to as buccal mucosa. Buccal mucosa has a tissue characteristic very similar to the native lining of the urethra and the mouth heals very well after harvest of this graft. Other options that are used for lengthy strictures include a piece of the penile skin. This is referred to as a penile circular fasciocutaneous flap and can be used on strictures that stretch throughout the penis.
Screening and Diagnostic Tests
Before undergoing the procedure, the patient may need to undergo the following investigations:
- Post-void residual volume.
- Retrograde urethrogram.
- Urine exam.
- Urinary flow rate.
- Urine culture.
Nearly 50% of men over the age of 50 will suffer from some sort of urinary dysfunction in their lifetime and many of these problems come from an enlarged prostate. Benign Prostatic Hyperplasia (BPH) is the medical term for an enlarged prostate gland and the symptoms that come with it.
How Rezūm Works
Using water vapor therapy, this minimally invasive procure has shown to significantly reduce the symptoms of BPH.The Rezūm therapy is completed in a single visit; there is no need for ongoing therapy.
It works by delivering very small amounts of steam to the enlarged prostate. This process damages the cells causing obstruction, thus reducing the overall size of the prostate and the symptoms associated with BPH such as:
- A weak urine stream
- Trouble starting the flow of urine
- Starting and stopping again when urinating
- Not emptying your bladder completely
- Urinating more often, especially at night
- Sudden urges to urinate
- Leaking or dribbling after you urinate
- Straining to urinate
Benefits of Rezum
- Procedure performed in-office, same day
- Does not require general anesthesia
- Noticeable symptom improvement within two weeks
- Preserves erectile and urinary functions
Transurethral Laser Vaporization of the Prostate (TVP)
Surgical procedures that employ side-firing laser fibers and lasers to vaporize obstructing prostate tissue are also used to treat BPH. A laser fiber is passed into the urethra near the prostate using a cystoscope and then several bursts of energy lasting 30 to 60 seconds are delivered through the laser fiber. The laser energy destroys prostate tissue and causes shrinkage. As with TURP, laser surgery requires anesthesia but is generally done as an outpatient procedure. One advantage of laser surgery over TURP is that laser surgery causes less blood loss and allows for a quicker recovery.
Transurethral Resection of Prostate (TURP)
Transurethral Resection of the Prostate (TURP) is a procedure to treat excessive growth of the prostate gland, resulting from Benign Prostatic Hyperplasia (BPH). BPH is not cancer. It is a common part of aging. When the prostate gland is enlarged, it can press the urethra and interfere with or block the passage of urine out of the body.
The procedure is performed with a small instrument and a fiberoptic camera that is passed through the natural opening in a man’s penis that he urinates through. There are no incisions. New state of the art bipolar technology is used by urology associates to minimize bleeding. This allows saline (same solution that is in all the cells in the body) to be used for irrigation. This prevents absorption of irrigation fluid that could cause harmful side effects.
- No incisions are needed
- Can be performed as an outpatient procedure.
- Immediate removal of excess tissue
- Can be coupled with other procedures, e.g., removing small bladder stones
- Symptom relief is immediate and durable
Percutaneous Nephrolithotomy (PCNL)
For kidney and ureteral stones that are too large (usually larger than 2 centimeters), too numerous, or too dense to be treated by the Extracorporeal Shock Wave Lithotripsy (ESWL) PCNL (percutaneous nephrolithotomy or stone extraction), a minimally invasive method of removing these stones is recommended.
Percutaneous nephrolithotomy, or PCNL, is performed under general anesthesia. During the procedure, your doctor makes a small incision in your side about the size of a fingertip. A narrow tunnel is then created directly into the kidney. A special telescope (called a nephroscope) is used to examine the inside of the kidney. Stones are broken by high speed vibration or a laser. This procedure usually requires a one to three day hospital stay and most patients resume normal activity within two weeks.
Ureteral Stent Placement
What is a ureteral stent?
A ureteral stent is a small hollow plastic tube inserted into the ureter to treat or prevent a blockage that prevents the flow of urine from the kidney to the bladder. The stent may be placed for temporary relief. Other reasons include stricture (abnormal narrowing of the ureter), and outside forces such as a tumor pushing on the ureter and causing a blockage.
Ureteroscopy with Laser Lithotripsy
Kidney stones that are present within the inner aspect of the kidney can be treated by a procedure called flexible ureteroscopy. This involves placing a small camera through the urethra, up the ureter and into the kidney to the kidney stone. The stone is broken into tiny fragments using a small laser called a Holmium laser. While this treatment is a well-established option for treatment of these stones, there are several different techniques used to help eliminate them from the kidney.
The stone can be removed by “basket” extraction whereby the ureteroscope is passed back and forth into the kidney to remove all visible stone fragments. It can also be removed by a method called “dusting” whereby the stones are broken into tiny fragments or “dust” with the intention that achieving such a small stone size will allow the stones to pass spontaneously.
The procedure is done as an outpatient under anesthesia, either general or spinal.
In most cases a ureteral stent (piece of surgical plastic that goes from the kidney to the bladder through the ureter) will be placed at the end of the procedure. The stent keeps the ureter open following surgery. If a stent is not placed the ureter may temporarily swell shut or become occluded by blood clots or stone debris resulting in kidney pain following surgery.
Extracorporeal Shock Wave Lithotripsy
The Extracorporeal Shock Wave Lithotripsy (ESWL) technique uses sound waves (also called shock waves) to break a kidney stone into very small pieces that can more easily travel through the urinary tract and out of the body. ESWL is usually reserved for stones that are in the kidney and not in the ureter. ESWL is not appropriate for women who are pregnant, people with a kidney or urinary tract infection, those with certain anatomic abnormalities and anyone with a bleeding disorder. ESWL is usually reserved for stones that are in the kidney and not in the ureter.
This procedure is popular because:
- Minimally invasive
- Takes only about an hour
- Can be done on an outpatient basis and requires little recovery time.( It may take a few weeks, however, for all the fragments to pass)
Transurethral Resection of Bladder Tumor (TURBT)
Transurethral resection (TUR) of the bladder is a surgical procedure that is used both to diagnose bladder cancer and to remove cancerous tissue from the bladder. This procedure is also called a transurethral resection for bladder tumor. General anesthesia or spinal anesthesia is often used. During surgery, a cystoscope is passed into the bladder through the urethra. A tool called a resectoscope is used to remove the cancer for biopsy and to burn away any remaining cancer cells.
Radical Cystectomy and Urinary Diversion
In a radical cystectomy, the surgery is performed either in an open or robotic fashion.
- In the open operation, an incision is made from the pubic bone to the belly button.
- In the robotic operation, several small incisions are made to allow introduction of the Da Vinci robotic instruments and camera.
Partial and Total Penectomy
Often times, it may be recommended that men with penile cancer undergo surgery. In certain situations removal of the penis (called penectomy), in part or in whole, may be recommended; additional procedures may accompany the penectomy and include removal of the scrotum and lymph nodes. Emasculation is the removal of the penis and testicles, typically, this is performed to treat advanced cancers.
- This involves removal of the end of the penis. This operation is used for penile tumors that are small and located towards the tip of the penis.
- A stump of penis is left behind through which the patient urinates and ejaculates.
- If an inadequate length of stump is left behind, the entire penis is removed (see Radical (Total) Penectomy, below.
- Patients are followed closely for any sign of recurrence.
- This operation is rarely used in conjunction with a lymph node dissection.
Radical (Total) Penectomy
- This involves removal of the entire penis and urethra (the tube through which urine exits the body). This operation is used for penile tumors that are large and located in the middle or at the base of the penis. Also, this operation is used when a partial penectomy is attempted but adequate length is not achieved.
- The urethra is redirected to the area between the scrotum and rectum (perineal urethrostomy). The patient must sit to urinate and cannot ejaculate. The testes are left in place so reproduction is possible, but only through surgery to harvest sperm from the testes followed by in vitro fertilization.
- Patients are followed closely for any sign of recurrence.
- This operation is often used in conjunction with a lymph node dissection.
Emasculation: During emasculation, the penis and testicles are removed. Typically, this is performed to treat advanced cancers.
Open Radical Prostatectomy
Open Radical Prostatectomy is surgery to remove the entire prostate gland and surrounding lymph nodes. This surgery is a treatment for men with localized prostate cancer. A surgeon can perform a radical prostatectomy using different techniques.
The operation may be done by open surgery or it may be done by laparoscopic surgery through small incisions. In open surgery, the surgeon makes an incision to reach the prostate gland. Depending on the case, the incision is made either in the lower belly or in the perineum between the anus and the scrotum.
Your surgeon will make a cut (incision) in your lower belly and remove the prostate through this opening. This type of surgery allows your physician to assess the prostate gland and surrounding tissue at the same time, while reducing injury to nearby organs. The prostate gland is removed with limited blood loss. The neurovascular bundles are preserved, and so is erectile function.
Open Radical Nephrectomy
Radical’ nephrectomy is the remove the whole of your kidney, including the surrounding fatty tissue, lymph nodes, adrenal gland and upper end of your ureter (tube carrying urine from the kidney to the bladder).. ‘Open’ refers that the kidney is usually removed via an incision (cut) which is made on either the front or the side of your abdomen. The type of cut made will depend on the nature of your tumor. The operation is performed under a general anesthetic.
Hand-Assisted Laparoscopic Adrenalectomy
Surgical removal of an adrenal gland, or adrenalectomy, is most commonly performed for a tumor located within the adrenal gland that is either producing too many hormones or is potentially cancerous. Frequently, the hormones produced by an adrenal tumor can cause high blood pressure, headaches, tremors, and other symptoms. Generally, patients are referred for an adrenalectomy after an abdominal CT scan reveals an enlarged adrenal gland.
Bladder Biopsy and Fulguration
A diagnostic or therapeutic procedure during which a small bladder tumor can be biopsied and destroyed.
A biopsy is a procedure in which a doctor takes a tissue sample from the area where cancer may exist. During the biopsy procedure, the doctor also will try to remove the cancerous growth. This is called resectioning. The entire procedure for bladder tumor biopsy and resection is known as Transurethral Resection of Bladder Tumor (TURBT), or sometimes just transurethral resection (TUR).
Female Urethral Slings
Mid-urethral slings have become the most common method to treat stress urinary incontinence (SUI). They are typically placed in under 30 minutes in an outpatient setting and are popular with patients due to the high cure rate, relative ease of placement, low complication rate and quick recovery.
The sling acts like a backboard and supports the urethra during straining maneuvers such as coughing, sneezing, laughing, jumping and exercise. It prevents it from descending, thereby preventing urine loss.
Injection of the Urinary Sphincter with Microplastique
Macroplastique is an injectable soft-tissue urethral bulking agent for treating adult female stress urinary incontinence primarily due to intrinsic sphincter deficiency. Macroplastique is injected into the tissues surrounding the urethra. The increased “bulk” allows the urethra to close more effectively and prevents urine from leaking.
The procedure to inject Macroplastique can be performed in your doctor’s office or in an outpatient clinic or hospital in approximately 30 minutes. Prior to the procedure, the doctor will give you an antibiotic to reduce the risk of infection. Upon the start of the procedure, the doctor will give you local anesthetic in the tissues near your bladder to reduce discomfort.
A small optical instrument (cystoscope), placed in the urethra, is used during the procedure to allow your doctor to view your urethra and bladder while injecting Macroplastique into the surrounding urethral tissue. Your doctor will also fill your bladder to halfway with water or saline to better view the implantation area. The optical instrument is removed after the injection and your treatment is complete.
Botox de-innervation of the bladder is an out-patient procedure that can be used to treat severe bladder symptoms by blocking the ability of some nerves to communicate with bladder or sphincter muscles.
Bladder BOTOX® is injected using a specialized scope and needle injection into the bladder muscle used to treat Overactive Bladder (OAB) symptoms such as a strong need to urinate with leaking or wetting accidents (urge urinary incontinence), a strong need to urinate right away (urgency), and urinating often (frequency) in adults 18 years and older when another type of medicine (anticholinergic) does not work well enough or cannot be taken. The out-patient procedure takes about 15 minutes or less and can be done under local anesthesia, sedation or general anesthesia. In the vast majority of patients, it can be done under local anesthesia on an outpatient basis. Rarely, a catheter will be required for a couple of days after the procedure.
Bladder BOTOX® works by calming the nerves that trigger the overactive bladder muscle, helping to:
- Reduce daily leakage episodes (accidents)
- Treat the strong need to urinate right away
- Reduce the number of times you need to empty your bladder daily
Transcutaneous Electrical Nerve Stimulation
Transcutaneous Electrical Nerve Stimulation (TENS) Uses low electrical pulses sent through wires placed on the low back or above the pubic area to relieve pelvic pain and decrease urinary frequency. Sacral nerve stimulation sends impulses to the sacral nerves (the link between the bladder and the spinal cord), reducing urinary urgency.
Artificial Urinary Sphincter
An artificial urinary sphincter is an implanted device which compresses the patient’s urethra to keep it closed except when voiding. Severe stress incontinence can sometimes develop after prostate or pelvic surgery or secondary to damage to the nerves going to the muscles that control continence. It is indicated for patients with severe incontinence. An inflatable cuff fits around the urethra and prevents urine from leaking. When a man wants to urinate, he squeezes a pump placed inside the scrotum. The pump deflates the cuff, urine is released, and then the cuff automatically re-inflates. This type of incontinence surgery may be an option for men experiencing incontinence due to nerve damage or weakened sphincter muscles.
Advanced Male Sling
The AdVance Male Sling is placed in the body and acts as a hammock, repositioning and supporting the urethra to help restore bladder control. It is indicated in patients with mild to moderate stress urinary incontinence who have not had pelvic radiation. Most patients have long-term success with the AdVance Male Sling and are classified as cured or improved.
The physicians of Urology Associates of Central Missouri have extensive experience in robotic pyeloplasty for the reconstruction of congenital kidney blockages. During the robotic pyeloplasty procedure, surgeons reattach the healthy portion of the kidney to the ureter, or the set of narrow tubes that transport urine from the kidneys to the bladder. The robotic pyeloplasty technique restores urine flow and allows complete reconstruction to be achieved in 95% of patients undergoing the procedure.
Benefits of Robotic Pyeloplasty
The benefits of our physicians using the robot to perform this procedure include:
- Better precision
- Improved outcomes
- Faster recovery
- Less post-operative pain
- No disfiguring incision
Robotic Radical Prostatectomy
Robotic prostatectomy used as a treatment approach for patients with early stage or localized prostate cancer. It offers a minimally invasive treatment with less blood loss and a more rapid overall recovery.
When complete removal of the prostate is indicated, the majority of prostatectomies are conducted via the minimally invasive, da Vinci robotic-assisted surgical system.
Benefits to patients
- Reduced pain and trauma to the body
- Less blood loss and need for transfusions
- Less post-operative pain and discomfort
- Less risk of infection
- Shorter hospital stay
- Faster recovery and return to normal daily activities
- Less scarring
The da Vinci Surgical System has been used successfully in thousands of prostate cancer procedures around the world. Most patients are able to return to normal activity in two-to-three weeks instead of the six-to-eight weeks more common with standard “open” surgery. There is less blood loss during a robotic-assisted prostatectomy, resulting in a higher blood count. The higher blood count provides for quicker return of strength and stamina after surgery. Of course, as with any surgical procedure, these benefits cannot be guaranteed. Successful outcomes depend on both the patient and the procedure.
Urodynamic tests for urinary incontinence are measurements taken to evaluate your bladder’s function and efficiency. The actual tests done vary from person to person. Urodynamic studies (UDS) test how well the bladder, sphincters, and urethra hold and release urine. Tests can show how well the bladder works and why there could be leaks or blockages.
Urodynamics help find the cause of problems related to:
- Urine leaks/controlling your urine
- Bladder not emptying all the way
- The need to go too often
- The need to go suddenly
- Weak urine flow
- Urine flow stopping and starting (“intermittent”)
- Getting urinary tract infections often
Types of Tests
There are many types of urodynamic tests. A health care provider may recommend one or more based on your symptoms, but they are typically performed together as one test.
Common tests, which are explained on the following pages, are all UDSs:
- Cystometry, or Getting a Cystometrogram
- Electromyography, or getting an Electromyogram (EMG)
- Urethral Pressure Profile
- Voiding Pressure Study (Pressure Flow Study)
Penile Injection Testing
Intracavernous injection therapy (penile injection therapy)
The process whereby a small amount of a chemical is injected directly into the corpora cavernosa (the cavity in the penis that fills up with blood causing a rigid erection). These chemicals are smooth muscle relaxants and thus help increase blood flow into the penile vessels. The advantage of this treatment is that it is reversible and less invasive than surgery. The disadvantage is that it is not spontaneous and the erection does not go away until the medicine wears off even if you climax or orgasm. There is a risk of priapism or prolonged erection which can be a medical emergency. For this reason the initial testing is performed in the office so that an antidote can be given if too strong a dose is given. Patients should see emergent medical treatment for an erection lasting longer than 4 hours.
Surgical procedure aimed to straighten penis curvature, one of the main symptoms of men with Peyronie’s Disease.
Excision of Penile Plaque and Grafting
Grafting surgery is surgical procedure that uses grafts to straighten bent penis and offers good cosmetic correction for men with severe penile deformity.
Xiaflex (collagenase clostridium), a FDA approved medication approved for the treatment of Dupuytren’s contractions resulting in a relief and improvement in a deformity associated with this condition. Xiaflex appears to be of benefit to men with significant penile deformities (greater than 30 degrees) who are interested in improving their curvature.
The absence of sperm from the ejaculate (azoospermia) is found in 15% of infertile men and obstruction of the ductal system is responsible for approximately 40% of cases. Obstructive azoospermia may result from epididymal, vasal, or ejaculatory duct pathology. Vasectomy is the most common cause of vasal obstruction. Severe genitourinary infections, injury during scrotal or inguinal surgery such as hernia repairs are other common causes of obstructive azoospermia. Microsurgical reconstruction of the reproductive tract is preferable to sperm retrieval with in vitro fertilization/intracytoplasmic sperm injection in men with prior vasectomy if the obstructive interval is less than 15 years and no female fertility risk factors are present. If epididymal obstruction is present, the decision to use either microsurgical reconstruction or sperm retrieval with in vitro fertilization/ intracytoplasmic sperm injection should be individualized. Vasoepididymostomy should be performed by an expert in reproductive microsurgery.
Sperm retrieval/ICSI is preferred to surgical treatment when:
- advanced female age is present
- female factors requiring IVF are present
- the chance for success with sperm retrieval/ICSI exceeds the chance for success with surgical treatment
- sperm retrieval/ICSI is preferred by the couple for financial reasons.
Da Vinci Robotic Surgery
The da Vinci System consists of a surgeon’s console that is typically in the same room as the patient and a patient-side cart with four interactive robotic arms controlled from the console. Three of the arms are for tools that hold objects, act as a scalpel, scissors, bovie, or unipolar or dipolar electrocautery instruments.
The fourth arm is for an endoscopic camera with two lenses that gives the surgeon full stereoscopic vision from the console. The surgeon sits at the console and looks through two eye holes at a 3-D image of the procedure, meanwhile maneuvering the arms with two foot pedals and two hand controllers.
The UroLift® System is a new, minimally invasive approach to treating BPH for patients looking for an alternative to drug therapy or more invasive surgery. The UroLift System is a straightforward procedure that utilizes tiny implants to lift and hold the enlarged prostate tissue out of the way so it no longer blocks the urethra. There is no cutting, heating or removal of prostate tissue.
The UroLift System is clinically proven to be safe and effective and provides rapid symptom relief. Typically, the procedure is done in the physician’s office under local anesthesia and does not require a catheter to be placed. A unique benefit of the UroLift System is that it preserves a man’s sexual function. The goal is to relieve you of bothersome urinary symptoms so you can get back to your life and resume daily activities.
Clinical studies have demonstrated that the UroLift procedure provides a similar level of symptom relief (compared with other BPH procedures), with fewer side effects. Most common adverse events reported include hematuria, dysuria, micturition urgency, pelvic pain, and urge incontinence. Most symptoms were mild to moderate in severity and resolved within two to four weeks after the procedure.