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General Urology

General Urology is a surgical subspecialty dedicated to the diagnosis and treatment of diseases related to the male and female genitourinary organs including the kidneys, adrenals, ureters, bladder, penis, testes, and prostate.

A Urologist is a physician who has completed a certified residency training program. A board certified Urologist has successfully completed oral and written exams conducted by the American Board of Urology. Urologists must repeat certification exams every 10 years. Urologists have specialized knowledge and skill with regard to problems of the male and female urinary tract and the male reproductive organs. Although Urology is classified as surgical subspecialty, the Urologist requires knowledge of internal medicine, pediatrics, gynecology, and other specialties.

Conditions treated by General Urologists include:

BPH

BPH is the non cancerous enlargement of the prostate. The prostate gland encircles the urethra in males and produces a fluid that makes up part of the semen. As the prostate enlarges, it can put pressure on the urethra causing a slowing of the urinary stream, hesitancy, frequency and dribbling. It can also cause urinary retention- the inability to urinate.

Complications from BPH may include urinary tract infections, weakening of the bladder muscle, hematuria (blood in the urine), renal failure, impaired sexual function and bladder stones.

The type and severity of symptoms experienced will vary from person to person and may change over time. For many men, BPH never progresses beyond a minor to moderate annoyance; for others, it may greatly impair their quality of life.

Testing

A diagnosis of BPH involves a physical exam, a digital rectal examination (DRE) and an evaluation of the patients symptoms. Laboratory tests may include:

  • PSA (Prostate specific antigen)- to help screen for prostate cancer
  • Urinalysis and culture- to rule out kidney disorders and urinary tract infections
  • Blood urea nitrogen (BUN and Creatinine- Blood tests to evaluate kidney function.

Non- Laboratory tests may include:

  • Bladder and Prostate ultrasound- To help measure the size of the prostate and evaluate the volume of urine retained in the bladder
  • Cystoscopy- To evaluate the urethra and bladder with a small flexible scope
  • Prostate biopsy- To rule out prostate cancer

Treatment

Treatment decisions are based upon each patients condition. The pros and cons of each option are discussed in detail during treatment planning.

Behavioral Therapy 

Examples include reducing fluid intake in the evening and eliminating bladder irritants from the diet.

Medications

In patients who have moderate symptoms, medications are used to control BPH.

  • Alpha blockers- relax the muscles around the prostate and bladder neck. Work quickly to relieve symptoms
  • 5-alpha reductase inhibitors- shrinks the prostate gland. May take months to work.
  • Anticholinergics- used to delay the urge to urinate, inhibits involuntary contractions.

Minimally invasive Therapies

  • Microwave thermal therapy (TUMT)- Outpatient procedure that takes about 1 hour. With the aid of a special urinary catheter a tiny antenna delivers microwave energy to heat and destroy the enlarged prostate tissue.
  • Laser Therapy
    • Photoselecive vaporization of the prostate (PVP, Greenlight)- uses laser energy to destroy prostate tissue.
    • Holmium laser ablation (HoLap) also uses laser energy to destroy prostate tissue.

Surgical Treatments

  • Transurethral resection of the prostate (TURP) Transurethral resection of the prostate (TURP) is a procedure frequently used to treat moderate to severe BPH. It was one of the most common major surgeries performed on men age 65 and older but is rapidly being replaced by laser prostatectomy and other less invasive procedures
  • Transurethral incision of the prostate (TUIP) uses special cutting instruments inserted through the urethra. TUIP differs from TURP in that no prostate tissue is removed. Instead, your surgeon makes one or two small cuts or grooves in your prostate gland where your prostate meets your bladder. The cuts allow the urethra to expand, making it easier to urinate

Open prostatectomy is usually done in men who have a greatly enlarged prostate gland, bladder damage or other complicating factors, such as bladder stones.

Stone Disease

A comprehensive program for the diagnosis, treatment and prevention of urinary stone disease is offered. The initial evaluation of a patient with stone disease is carefully performed to determine the number, size and location of the stone burden. Imaging studies are performed to demonstrate kidney function, the patient's anatomy and the CAT scan characteristics of the stone(s) degree of "hardness". The number, size, location and "hardness" of the stones provide vital information for planning the most efficient treatment strategy for each individual patient.

Treatment of Urinary Stones

Today, there are many choices for removing urinary stones. We offer all the available options for treatment:

  • Medical Expulsive Therapy - use of medication and hydration to pass small stones (85% of stones can be safely managed in this manner)
  • Medical Dissolution of Stones - stones of uric acid composition, that are not obstructing can be dissolved over time by increasing the alkalinity of the urine with dietary modification and medication
  • Shock Wave Lithotripsy - the fragmentation of stones by high energy shock waves generated outside the body. This technique is performed under a "twilight" anesthesia, as an outpatient. SWL is ideal of smaller stones, too large to pass, in the kidney and ureter. It is the most commonly used treatment of symptomatic stones.
  • Ureteroscopy and Laser Lithotripsy - for stones in the ureter or kidney that are not candidates for shock wave lithotripsy due to their size or hardness. For this technique, general anesthesia is used. A very thin fiber optic instrument, equipped with video capability to generate high resolution magnified images is advanced into the ureter or kidney. Stones identified are fragmented wit laser energy. The small fragments can be extracted or left to pass spontaneously, depending on size.
  • Percutaneous Nephrolithotomy - for large kidney or upper ureteral stones. This technique, performed under general anesthesia, calls for the placement of a fine needle, under ultrasound/x-ray guidance, into the kidney. A balloon dilator is placed over the needle/safety wire in order to dilate a tract from the skin to the inside of the kidney. A sheath is placed over the balloon so that a safe passageway is established for the introduction of a video-scope that allows the surgeon to directly view the stones in the kidney. To break up the stones ultrasound energy, laser energy, or a "jack-hammer" type device is used. The small resultant fragments are then safely removed with graspers through the access sheath. An overnight hospital stay is required for this technique.
  • Robotic/Laparoscopic Stone Surgery - for very large stones that are not amenable to treatment by the above techniques and would otherwise require open surgery; also for stones associated with structural abnormalities of the ureter or kidney that require surgical correction at the time of stone removal.
  • Open Surgery - the option of last resort. Rarely used in today's practice

Prevention of Stone Disease

Emphasis is placed on a complete metabolic work up to identify the reasons for recurrent stone formation in each individual patient. The work up includes a review of the patient's past stone history, family history, with special attention paid to diet, eating habits and food preferences, physical activity and fluid intake.

One or two 24-hour urine collections are performed at home to assess the balance of stone promoters and stone inhibitors present in the patient's urine. Additional specific blood tests may be required to complete the metabolic evaluation.

Taken together, this information allows the generation of a specific plan for stone prevention for each individual patient. Dietary and fluid intake recommendations are made; if necessary medication

Urinary Diversion

This is what occurs when urine needs to be temporarily diverted because of urinary obstruction and/or infection. This is usually performed by inserting a Ureteral stent or by performing a percutaneous nephrostomy which are described below.

Ureteral Stents

What is a Ureteral Stent? 
A stent is a narrow, hollow plastic tube that runs between the kidney and bladder, inside of the conduit that normally carries urine between those organs called the ureter. The stent functions to hold the ureter open and allow drainage of urine and allows the kidney to function properly.

Why are they used?
There are a variety of reasons why a stent has been placed. For patients undergoing stone surgery, the stent allows passage of residual fragments without blocking the ureter. Patients who have had ureteroscopy (a look up the ureter) have a stent placed to allow the ureter to remain open while the normal postoperative swelling of the ureter resolves. Patients who have had any form of surgery on the ureter have a stent placed to allow healing of the ureter in the proper open fashion.

The stent is held in place by its design, which incorporates "pig tail" spiraling where it is located in the kidney and bladder. Occasionally, a blue suture is attached to the end of the stent and comes out of the body through the urethra ( the urine tube leading from the bladder outside the body. If you have such a blue string present, under no circumstances pull on it, as it will cause the stent to become dislodged. Be especially careful when bathing, not to catch the string on the terry cloth towel. 

Percutaneous Nephrostomy (Upper Urinary Tract Diversion)

Urine is diverted by placing a tube through the skin of the patient’s flank into the kidney. This is usually performed under local anesthesia and with sonographic or radiographic guidance.

What is permanent urinary diversion?
When the urinary bladder is removed (due to cancer, other medical condition, or because the organ no longer works), another method must be constructed for urine to exit the body. Urinary reconstruction and diversion is a surgical method to create a new way for urine to exit the body.

There are three main types of permanent urinary diversion surgeries:

  • Ileal Conduit Urinary Diversion
  • Indiana Pouch Reservoir
  • Neobladder to Urethra Diversion

For all of these procedures, a portion of the small and/or large intestine is disconnected from the gastrointestinal (fecal) stream and used for reconstruction.

ILEAL CONDUIT: This reconstruction includes removing an approximately 8 inch segment of small intestine, which will remain on its vascular stalk to insure a continuous blood supply. The gap in the remaining small intestines is reconnected, and one of the open ends of the removed 8 inch segment is closed. The ureter(s) will be connected to the free segment of intestine or "conduit" at the side of the closed end. Finally, the open end of the segment is connected to the skin as an opening, or stoma, at the lower aspect of the abdomen. Urine will continuously drain from the stoma, so it is necessary to wear an appliance to collect it. The appliance sac will need to be emptied manually approximately 3-4 times per day. At nighttime, individuals can connect their appliance sac to a larger collection bag, obviating the need to empty their urine during sleep. The urinary conduit is the simplest of the 3 reconstructions, and has the lowest rate of complications.

CATHETERIZABLE STOMA: A modification of the urinary conduit, the catheterizable stoma enables an individual to excrete urine from their stoma without the need for an external appliance. The stoma is modified into a one-way valve so that urine cannot leak out. Usually , a larger segment of large intestine is removed, and fashioned into a reservoir or "pouch" for holding approximately pint of urine. By inserting a rubber catheter into the stoma, urine is easily drained from the reservoir. This reconstruction requires individuals to have a level of dexterity and self-motivation to perform the catheterization several times each day. Unlike the urinary conduit, individuals cannot connect their stoma to a larger drainage sac at night, but rather must awaken at least once to empty their reservoir.

NEOBLADDER: The most technically complex reconstruction results in no external device but rather connects the intestinal reservoir to the urethra (the tube that exits urine naturally from the body). The neobladder is cosmetically attractive. This operation is far more complex for several reasons. First, the connection of the reservoir to the urethra is technically more difficult since it is deep within the pelvis. The complexity of this connection may lead to complications such as scarring leading to urinary retention; or internal leakage leading to urine collections that can become infected. Additionally, because the removal of the bladder includes part of the urinary sphincter responsible for continence, it is possible that there will be significant urinary leakage or frank incontinence. Also because the intestinal reservoir does not have the same innervation and musculature as does the bladder, the ability of the reservoir to contract and therefore excrete the urine is fairly limited. Because of this potential scenario, individuals must be motivated in and capable of performing self-catheterization through their native(original) urethra. Nevertheless, in most cases careful training and rehabilitation teach individuals to exert internal abdominal pressures in order to excrete urine. It should be noted that the extent of local bladder cancer may impact on the safety and efficacy of this reconstruction from a cancer-control standpoint.

Here is the internal view of a neobladder. Intestine has been made into a pouch and the ureters are connected to the top while the pouch itself is connected to the urethra  is used to further decrease to the risk of stone formation.

 

Urinary Incontinence

By definition, urinary incontinence means involuntary leakage of urine. This can be a distressing problem that affects your quality of life. There are different kinds of urinary incontinence, including stress incontinence, urge incontinence, overflow incontinence, and mixed incontinence. Involuntary leakage of urine may occur due to a number of reasons including excessive production of urine, bladder irritation, neurologic or muscular disorders, or prostate problems in men. We are able to do various studies in the office to determine the cause of your incontinence.

Types of incontinence:

  • Stress incontinence—leakage of urine with stress or an increase in abdominal pressure with activities such as coughing, sneezing, laughing, or exercise
  • Urge incontinence—loss of urine after feeling a strong urge or need to urinate
  • Overflow incontinence—dripping of urine out of a bladder that is already filled to its capacity
  • Mixed incontinence—a combination of other types of incontinence

Diagnostic Studies

A number of studies can be done to better understand the type of incontinence you have and what may be causing it. These studies include:

  • Physical exam—thorough exam of the entire body to look for signs of underlying medical problems that may contribute to incontinence
  • Urinalysis—the urine is tested for evidence of infection, kidney stones, or other contributing causes
  • Ultrasound—sound waves are used to better visualize the kidneys, ureters, bladder, and prostate
  • Cystoscopy—a camera is placed inside the urethra and bladder to visualize the lining of these organs; this allows us to diagnose tumors, stones, inflammation, or fistulas of the bladder / urethra
  • Urodynamics—a procedure performed in the office to help us better understand the activity of the bladder; we study the bladder pressure as well as the flow of urine

Treatment

There are different ways to treat urinary incontinence depending on the type and cause of leakage. The most conservative treatment is behavioral modification. Often decreasing the amount of fluid you are drinking may decrease the amount of leakage. Avoiding bladder irritants such as caffeine, alcohol, and spicy foods may help as well. Treating underlying medical problems such as diabetes or an enlarged prostate is also useful in treating incontinence.

Physical therapy can be helpful for those with stress incontinence. A licensed physical therapist can teach you the proper exercises to strengthen the pelvic floor muscles and thus eliminate or decrease the amount of leakage. Other options include injection of a bulking agent into the urethra or surgical placement of mesh (a “sling”) under the urethra to give you more support.

There are many medications available by prescription to help relax the bladder and eliminate urge incontinence. Injection of Botox into the bladder is another treatment option for urge incontinence. A bladder “pacemaker” device called Interstim™ can be implanted to help with urgency and urge incontinence as well.

You will need an appointment with one of our board certified urologists to further discuss the best treatment option for you.