Conditions & Treatments

Robotic Assisted Laparoscopic Surgery

The da Vinci Surgical System is the only FDA Approved Technology available that can provide the surgeon with the range of motion, fine tissue manipulation capability and 3-D visualization characteristic of open surgery, while simultaneously allowing the surgeon to work through tiny incisions typical of laparoscopic surgery.

The da Vinci System has three main parts: the console, where the surgeon sits to operate the robot; the patient side cart, which is positioned over the operating table and contains the arms that hold the instruments; and a third cart which provides a view of the surgery for the other doctors and nurses in the room. When the surgeon looks into the console, he sees a three-dimensional view of the patient’s internal organs and the surgical instruments, similar to what he would see in an open operation.

Unlike an open operation, the camera can magnify the image, creating better visualization. The arms of the robot on are controlled by the surgeon using hand controls. Perhaps the largest advantage of the robot is in the design of the instruments. Unlike most laparoscopic instruments (which can only move in certain directions) the da Vinci’s instruments are wristed. The surgeon can manipulate the instruments in multiple directions, giving the surgeon freedom similar to that of an open platform.

There are limitations to robotic surgery. Unlike an open operation, the surgeon cannot feel the organs. When using the instruments to touch the organs, there is no tactile feedback, so surgeons must be extra vigilant about where each instrument is, in order to avoid damage to the organs. Finally, the da Vinci requires use of instruments that are manufactured only by Intuitive Surgical, Inc. If a procedure requires an instrument that is not currently available through the manufacturer, that part of the procedure must be completed laparoscopically.

Robotic surgeries have led to less invasive cancer surgeries with decreased pain and faster recovery times for patients. Because of the reduced size of the incisions, hospital stays are often shorter, with some patients even able to go home the next day.

During robotic surgery, several instruments, including a camera called a laparoscope, are inserted into the patient’s abdomen through small incisions. These instruments include scissors, graspers, and other instruments modeled after the typical instruments used in traditional open procedures.

Robotic surgery can help surgeons overcome many of the challenges presented by the open or laparoscopic surgery. We have one of the largest
experience with comprehensive robotic surgery in treating invasive bladder cancers with total bladder removal and urinary diversions (also known as Radical Cystectomy).

is a leader in applying the robotic-assisted da Vinci S Surgical System to combine extremely precise movements with three-dimensional imaging to achieve excellent surgical results.

Potential benefits of Robotic surgeries include:
  • Less blood loss, pain and visible incisions
  • Shorter hospital stays and recovery time
  • Fewer post-operative complications
  • Quicker return to normal activities

Urolithiasis (kidney stones) is a fairly common condition, with a prevalence of 10-15% of the US population. Stones are more common in Caucasians, followed by Hispanics, Asians, and African-Americans. Men are more likely than women to develop stones. Also, patients with a higher body mass index are more likely to form stones. Climate and location can also affect stone risk, with arid and warmer climates having a higher incidence. In the US, the Southeast has the highest incidence of stone formation and is referred to as the “Stone Belt”.

Diagnosis

The classic symptoms of a kidney stone include flank pain that radiates to the groin. This symptom may be referred to as “renal colic” and usually results from obstruction of urine passage from the kidney to the bladder through the ureter. Hematuria, or blood in the urine, may also be present. The pain may be significant enough to cause nausea and vomiting. Concomitant infection in the urinary tract may also be present and may cause a fever. Diagnosing a kidney stone is based on taking a history and performing a physical exam. In addition, lab tests and imaging studies are typically used to confirm the diagnosis. A medical history is obtained to better define the symptoms. Also, a personal history or family history of stones may be a contributing factor. Associated medical conditions that may increase the risk of stone disease may be identified, such as obesity, inflammatory bowel diseases, or recurrent urinary tract infections. Previous surgeries, including previous urinary tract surgery, or bowel surgery, may indicate the presence of stones. A focused physical exam, including vital signs such as temperature and heart rate, is performed. Flank or abdominal tenderness on the affected side is typically identified.

ESWL – Extracorporeal Shock Wave Lithotripsy

Definitive management of the stone depends on various factors. Several minimally invasive options are available for treatment. Extracorporeal shock wave lithotripsy (ESWL) uses shock waves passed through the skin to fragment the stone. ESWL is most commonly used for proximal ureteral stones and stones within the kidney that are less than around 1.5cm (or 15mm) in size. Typically, a ureteral stent may be placed before performing ESWL for larger stones (>1cm). The fragmented stone is then easily passed in the urine.

Ureteroscopy

Ureteroscopy can be used for stones anywhere in the ureter and some parts of the kideny. This procedure involves the passage of a small scope and camera through the urethra, into the bladder, and up the ureter of the affected side. Once the stone is identified, a laser can be used to fragment the stone or a small basket can be passed through the scope to grasp and remove the stone. Both ESWL and ureteroscopy have similar success rates for stones located in the proximal ureter and kidney. The success rate declines for both modalities as the size of the stone increases to larger than 1.5 cm. Ureteroscopy is typically used for stones located in the mid-portion of the ureter or in the distal ureter.

Percutaneous Nephrolithotomy & Ultrasonic Lithotripsy

Definitive management of larger stones (1-2cm) or multiple large stones in a kidney may require more invasive procedures.
Percutaneous removal of stones from the kidney can be used for large stones, especially those located in the lower portion of the kidney. This procedure involves placing a tube directly into the kidney through the back. This percutaneous tract is then dilated to allow passage of a scope with a camera attached. Several devices can then be used to fragment the stones and remove them from the kidney. Typically, these procedures require an overnight stay in the hospital. Very large stones in the kidney may require a combination of procedures, such as percutaneous removal and ESWL. Occasionally, patients with large stones impacted in the ureter or those with anatomic factors associated with stones may require laparoscopic or robotic procedures to remove the stones and correct the associated anatomic anomaly. For example, a patient with a stricture or obstruction between the kidney and the ureter (UPJ obstruction) may undergo repair of the obstruction and removal of the kidney stones using laparoscopic/robotic techniques.

Prostate Cancer

The prostate is the gland below a man’s bladder that produces fluid for semen. Prostate cancer is common among older men. It is rare in men younger than 40. Risk factors for developing prostate cancer include being over 65 years of age, family history, being African-American, and some genetic changes.

Symptoms of prostate cancer may include:

  • Problems passing urine, such as pain, difficulty starting or stopping the stream, or dribbling
  • Low back pain
  • Pain with ejaculation

Your doctor will diagnose prostate cancer by feeling the prostate through the wall of the rectum or doing a blood test for prostate-specific antigen (PSA). Other tests include ultrasound, x-rays, or a biopsy.

Treatment often depends on the stage of the cancer. How fast the cancer grows and how different it is from surrounding tissue helps determine the stage. Men with prostate cancer have many treatment options. The treatment that’s best for one man may not be best for another. The options include watchful waiting, surgery, radiation therapy, hormone therapy, and chemotherapy. You may have a combination of treatments.

Treatments Offered
Robotic Radical Prostatectomy

The most important aspect of choosing to undergo treatment of your prostate cancer is to maximize your chances for cure. Present day data from multiple centers around the United States demonstrate that Laparoscopic Assisted Prostatectomy using the daVinci® Robotic Surgical System has the potential to achieve comparable cancer control to open surgical prostatectomy; this is measured by prostate specimen margin free status. It is felt that the six degrees of freedom and 3-D Vision offered by the daVinci® Robotic Surgical System are key in helping to maximize prostate cancer surgical cure.

One of the biggest advantage of the daVinci® Surgical System over pure laparoscopic modalities is the ability to translate and facilitate human wrist movements into laparoscopic instrumentation. Therefore, more difficult segments of the operation are made easier. Many laparoscopic urologists, for example, feel that the reconstructive portion of the operation which entails the vesico-urethral anastomosis (when the bladder is sewn to the urethral after removal of the prostate) is performed with greater ease, quicker, and in a more “water-tight” fashion. As a result, patients have had their catheters and drains removed shortly after the operation.

Brachytherapy/Radiation Therapy
Active Surveillance
HIFU (High Intensity Focused Ultrasound)
Cryoablation
What Is Laparoscopic Nephrectomy?

Nephrectomy (removal of the kidney) is indicated in patients with an irreversibly damaged, non functioning kidney as well as in situations of kidney masses which are presumptive renal cell carcinoma, or kidney cancer. The procedure of traditional open nephrectomy usually involves a large incision, about 1 foot in length, sometimes requiring removal of a rib. The result of open surgery is pain and numbness over the affected side, which further interferes with normal respiratory movement and can prolong recovery. Laparoscopic nephrectomy is a standard of care. This surgery is performed via 3-4 small incisions (0.5 to 1cm in size) and has a significant number of benefits to the patient including decreased pain, shorter hospitalization (about 2 days), less blood loss, lower requirements for pain medication, reduced convalescence, and a more rapid return to full activity. Laparoscopic nephrectomies have been performed for over a decade, and data has shown this procedure to produce cancer control identical to that of open radical/total nephrectomy. At this time, laparoscopic radical/total nephrectomy for the treatment of renal tumors is a standard of care.

What Is Partial Nephrectomy?

Although radical nephrectomy is a standard surgery for management of renal cell carcinoma, either open or robotic/laparoscopic, nephron sparing surgery has become accepted for selected patients: those with solitary kidney, bilateral renal cell carcinoma or small renal cell carcinoma. Partial nephrectomy is another option of nephron sparing surgery other than laparoscopic.

Bladder Cancer

The bladder is a hollow organ in your lower abdomen that stores urine. Bladder cancer occurs in the lining of the bladder. It is the sixth most common type of cancer in the United States.

Symptoms include:
  • Blood in your urine
  • A frequent urge to urinate
  • Pain when you urinate
  • Low back pain

Smoking is a major risk factor for bladder cancer. Exposure to certain chemicals in the workplace is another. People with a family history of bladder cancer or who are older, white or male have a higher risk.

Treatments for bladder cancer include surgery, radiation, chemotherapy and biologic therapy. Biologic therapy, or immunotherapy, boosts your body’s own ability to fight cancer.

Treatments Offered:
    • Radical Cystectomy

  • TURBT (Transurethral Resection of Bladder Tumor)
What Is Robotic/Laparoscopic Adrenalectomy?

With improvements in diagnosis, precise radiological localization, preoperative medical management, anesthesia, and refined surgical techniques, surgical management of adrenal abnormalities with laparoscopic adrenalectomy is a safe procedure with a predictable outcome. It is now a standard of care. The diagnosis and management of disorders of the adrenal gland are among the most challenging and satisfying aspect of urological practice. Laparoscopic surgery has established a clear benefit to patients with adrenal diseases because of its minimal invasiveness and low morbidity. The role for open surgery is reserved for very large, > 5cm functioning adrenal cancers. Laparoscopic adrenalectomy is the optimal treatment for adrenal masses, for both hormonally functioning and nonfunctioning adrenal masses.

What is Laparoscopic Surgery?

Laparoscopy is a technique for performing major abdominal surgery through several tiny (0.5 to 1 cm) incisions, instead of the large, 12 inch incisions that have been used in the past. Laparoscopy involves a high resolution video camera so organs such as kidneys, adrenals, prostate, and ureters can be visualized with a 1-cm telescope, and manipulated with instruments through these small, 0.5 to 1 cm incisions on the abdomen. Because of their small size, these incisions produce much less discomfort after laparoscopy than the scar associated with large incisions required for open surgery. With laparoscopy, the need for pain medication, the length of hospital stay, and the recovery time are greatly reduced. Laparoscopic surgery requires general anesthesia. Although laparoscopic surgery is easier on the patient than open surgery, it requires great skill and technique which require specialized training.

Laparoscopy is established in the mainstream of urologic surgery. Indeed, it is becoming increasingly clear that almost all aspects of retroperitoneal surgery, be it kidney, ureter, adrenal gland, prostate, or lymph nodes, can now be achieved laparoscopically with far less injury and pain to the patient. Minimally invasive surgery is superseding open surgery at major medical centers throughout the world. In the new millennium, the old craft of open, large incision surgery has an ever-diminishing role in the treatment of urologic disease.

Benefits of Laparoscopic Surgery

Several documented benefits in comparison with traditional open surgery have been demonstrated including:

  • Less postoperative pain
  • Less blood loss
  • Shorter hospital stay
  • Favorable cosmetic result / smaller scars
  • Earlier return to work and normal daily activities
Laparoscopic surgery cannot be performed if you have:
  • Uncorrectable coagulopathy
  • Intestinal obstruction
  • Abdominal wall infection
  • Suspected malignant ascites

Also, relative contraindications include morbid obesity, extensive prior abdominal or pelvic surgery, ascites, pregnancy, severe chronic obstructive pulmonary disease (COPD), and severe cardiac arrhythmias or heart disease.

Complications

Complications are decreased in experienced surgeons who perform laparoscopy on a routine basis. The estimated complication rate of laparoscopic surgery is less than 5%. The associated mortality rate is about 0.3% and conversion rate was 1-5%. Risks of surgery include bleeding, infection, injury to adjacent organ such as liver, bowel, spleen or pancreas, as well as possible conversion to open surgery. Most intraoperative complications (2.5%) are vascular and bowel injuries, while postoperative complications (3%) were predominantly blood clots and wound infections. Conversion to open surgery might be necessary to safely complete the planned procedure, which occurs < 5% in experienced hands.

How is BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH—ranging from mild to severe.There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE),PSA testrectal ultrasoundurine flow study and cystoscopy.

When is surgical treatment suggested as a form of treatment?

When medical therapy fails, surgery is required to remove the obstructing tissue. Surgery is almost always recommended for men who are unable to urinate, have kidney damage, frequent urinary tract infections, significant bleeding or stones in the bladder.

What are the different surgical treatments available?

Removal of the prostate can be accomplished in several different ways. The location of the enlargement within the prostate and the patient’s general health will help the urologist determine which of the three following procedures to use.

Transurethral resection of the prostate (TURP):

Transurethral resection is the most common surgery for BPH. In the United States, approximately 150,000 people have TURPs performed each year. This can be done using electric current or with laser light. After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis. The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter. Since there are no surgical incisions with this procedure, patients normally stay in the hospital only one to two days. Depending on surgeon preference, the catheter may be removed while the patient is still in the hospital or the patient may be sent home with the catheter in place, attached to a leg bag for convenience and removed several days later as an outpatient procedure.

Laser Enucleation of the Prostate (HoLEP or ThuLEP) or Laser Vaporization

This techniques utilizes laser technology to achieve the same goal as TURP with equal efficacy and improved safety.  Most patients are able to be discharged the same day as their procedure and their catheters are removed the following day.  This is most effective on larger prostates larger than 60 grams.

Prostatectomy:

When a transurethral procedure cannot be done, Robotic or open surgery may be required. Prostatectomy for BPH is also performed for a prostate that is too large to remove through the penis. Other reasons for choosing a prostatectomy include patients with large bladder diverticula, with large bladder stones and those who cannot physically tolerate having their legs placed in stirrups for TURP/TUIP surgery.

Through small incisions, surgeons operate using a robotic platform with 3D-HD vision and miniaturized wristed instruments. Robotic prostatectomy enables surgeons to operate with enhanced visions, precision and control. This is important when it comes to preserving urinary and erectile function.  An incision is made in the abdominal wall from below the belly button to the pubic bone. The prostate gland can then be removed in its entirety through this process.  Postoperative pain is mild to moderate. Patients usually stay in the hospital for 1-2 days and go home with a urinary catheter. In some cases a second catheter draining the bladder through the lower abdominal wall is used.

What can be expected after treatment?

Postoperatively, patients typically experience significant improvement in their symptoms (table 1). As with any operative procedure, complications do exist. Some occur in the early postoperative period (table 2) while others may occur many years later (table 3).

Will surgery for BPH affect my ability to enjoy sex?

Most urologists say that even though it takes a while for sexual function to return fully, most men are able to enjoy sex again. Most experts agree that if you were able to maintain an erection shortly before surgery, you will probably be able to do so after surgery. Most men find little or no difference in the sensation of orgasm although they may find themselves suffering from retrograde ejaculation.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer. Still, both problems can happen at the same time. There may not be any symptoms during the early stages of prostate cancer. So whether their prostate is enlarged or not, men should talk to their health care providers about whether prostate cancer screening is right for them.

The urethra is an important part of the urinary tract. While it’s primary job in both genders is to pass urine outside the body, this channel also has an important role in ejaculating semen from the reproductive tract of men. Most people will not have any problems with the urethra, but a few of us may experience the discomfort and dysfunction associated with urethral stricture disease. What is this and how can it be treated? The information below should help you talk with your urologist.

What happens under normal conditions?

During urination, the bladder empties through the urethra and out of the body. Urine passes through an opening called the bladder neck into a portion of the urethra surrounded by the prostate, called the prostatic urethra. The next segment of the urethra is called the membranous urethra and it contains a muscle called the external urinary sphincter. This sphincter allows a patient to voluntarily hold urine and to stop during urination. Together, the prostatic urethra and the membranous urethra make up the posterior urethra, and are approximately one to two inches long. The urine then enters the bulbar urethra, followed by the penile urethra. The penile urethra is the segment that runs along the bottom surface of the penis. The exit at the tip of the penis is called the meatus. The bulbar urethra, penile urethra and meatus make up the anterior urethra, which is nine to 10 inches long.

What is a urethral stricture?

A urethral stricture is a scar in or around the urethra, which can block the flow of urine, and is a result of inflammation, injury or infection.

Who is at risk for urethral strictures?

Urethral strictures are more common in men because their urethras are longer than those in women. Thus men’s urethras are more susceptible to disease or injury. A person is rarely born with urethral strictures and women rarely develop urethral strictures.

What are some causes of urethral stricture?

Stricture disease may occur anywhere from the bladder to the tip of the penis. The common causes of stricture are trauma to the urethra and infections such as sexually transmitted disease or damage from instrumentation. However, in most cases, no cause can be identified. Stricture of the posterior urethra is often caused by a urethral injury associated with a pelvic bone fracture (e.g., motor vehicle or industrial accident). Patients who sustain posterior urethral injuries from pelvic fracture generally suffer a disruption of the urethra, where the urethra is cut and separated. These patients are completely unable to urinate and must have a catheter to realign the urethra. The catheter is placed through the penis up into the bladder to allow urine to drain until a repair can be performed. Trauma such as straddle injuries, direct trauma to the penis and catheterization can result in strictures of the anterior urethra. In adults, urethral strictures may occur after prostate surgery, removal of kidney stones, urinary catheterization or other instrumentation. In children, urethral strictures most often follow reconstructive surgery for congenital abnormalities of the penis and urethra, cystoscopy and urethral catheter drainage.

What are the symptoms of urethral strictures?

Some symptoms that may be an indication of urethral strictures can include:

  • painful urination
  • slow urine stream
  • decreased urine output
  • spraying of the urine stream
  • blood in the urine
  • abdominal pain
  • urethral discharge
  • urinary tract infections in men
  • infertility
How are urethral strictures diagnosed?

Simply put, the urethra is like a garden hose. When there is a kink or narrowing along the hose, no matter how short or long, flow can be significantly reduced. When a stricture becomes narrow enough to decrease urine flow, the patient will develop symptoms. Frequent urination, urinary tract infections and inflammation or infections of the prostate and scrotal contents (epididymis) may occur. With long-term severe obstruction, damage to the kidneys can occur.

Evaluation of patients with urethral stricture disease includes a physical examination, urethral imaging (X-rays or ultrasound) and sometimes urethroscopy. The retrograde urethrogram is an invaluable test to evaluate and document the stricture and define the stricture recurrence. Combined with antegrade urethrogram, length of the stricture in order to plan surgical correction can be determined. The retrograde urethrogram is performed as an outpatient X-ray procedure and can define indicate the number, position, length and severity of the stricture(s). This study involves insertion of contrast dye (fluid that can be seen on an X-ray) into the urethra at the tip of the penis. No needles or catheters are used. The retrograde urethrogram study allows doctors to see the entire urethra and outlines the area of narrowing at the stricture.

Ultrasound is performed by placing a small, pencil-like ultrasound wand on the skin over the stricture to view it and surrounding tissue. Urethroscopy is a procedure where the doctor gently places a small, flexible, lubricated telescope into the urethra and advances it to the stricture. This study permits the doctor to see the urethra between the tip of the penis and the stricture. All of these tests can be performed in an office setting and will allow the urologist to provide treatment recommendations.

In the case of urethral trauma, once emergency treatment has been provided, the evaluation of patients with posterior urethral disruptions involves a retrograde urethrogram, and if a suprapubiccatheter is present, injection of contrast dye through this tube at the same time. Contrast injected from below fills the urethra up to the injured area, and contrast injected from above fills the bladder and the urethra down to the stricture. These two films together allow the surgeon to determine the gap between the two ends in order to plan the surgical repair.

How can urethral strictures be prevented?

The most important preventive measure is to avoid injury to the urethra and pelvis. Also, if a patient is performing self-catheterization they should exercise care, to liberally instill lubricating jelly into the urethra, and to use the smallest possible catheter necessary for the shortest period of time.

Acquired strictures may be a result of inflammation caused by sexually transmitted infections (STIs). Although gonorrhea was once the most common cause of inflammatory strictures antibiotic therapy has proven effective in reducing the number of resulting strictures. Chlamydia is now the more common cause, but strictures caused by this infection may be prevented by avoiding contact with infected individuals or by using condoms. When infection does occur, prompt and complete treatment of the STI with appropriate antibiotics will help prevent future problems.

What are some treatment options?

Treatment options for urethral stricture disease are varied and selection depends upon the length, location and degree of scar tissue associated with the stricture. Options include enlarging the stricture by gradual stretching (dilation), cutting the stricture with a laser or knife through a scope (urethrotomy) and surgical removal (excision) of the stricture with reconnection and reconstruction possibly with grafts.

Dilation

This is usually performed in the urologist’s office under local anesthetic and involves stretching the stricture using progressively larger dilators called “sounds.” Alternatively, the stricture can be dilated with a special balloon on a catheter. Dilation is rarely a cure and needs to be periodically repeated. If the stricture recurs too rapidly the patient may be taught how to insert a catheter into the urethra periodically to prevent early closure.

Pain, bleeding and infection are the main problems associated with dilation procedures. Occasionally, a “false passage” or second urethral channel may be formed from traumatic passage of the “sound.”

Urethrotomy

This procedure involves use of a specially designed cystoscope that is advanced along the urethra until the stricture is encountered. A knife blade or laser operating from the end of the cystoscope is then used to cut the stricture, creating a gap in the narrowing. A catheter may be placed into the urethra to hold the cleft open for a period of time after the procedure to allow healing in the open position.

The suggested length of time for leaving a catheter tube draining after stricture treatment can vary.

Urethral Stent

This procedure involves placement of a metallic stent that has the appearance of a circular chain link fence. The stent is placed into the urethra through the penis using a specially designed cystoscopic insertion tool after the urethra is widened. The stent expands within the widened stricture and prevents the urethra from closing. The lining of the urethra eventually covers the stent, which remains in place permanently. This treatment has the advantage of being “minimally invasive.” However, it is only suited to very select strictures and frequently causes significant swelling around the device. Removal of these devices is very difficult and may result in a more significant stricture.

Open surgical urethral reconstruction

Many different reconstructive procedures have been used to treat strictures, some of which require one or two operations. In all cases, the choice of repair is influenced by the characteristics of the stricture (such as location, length and severity), and no single repair is appropriate for all situations. Open reconstruction of a short urethral stricture may involve surgery to remove the stricture and reconnect the two ends (anastomotic urethroplasty). When the stricture is long and this repair is not possible, tissue can be transferred to enlarge the segment to normal (substitution procedures). Substitution repairs may need to be performed in stages in difficult circumstances.

Anastomotic Procedures

These are usually reserved for short urethral strictures where the urethra can be reconnected after removing the stricture. This procedure involves a cut between the scrotum and rectum. This is usually performed as an outpatient procedure or with a brief hospitalization. A small, soft catheter will be left in the penis for 10 to 21 days and removed after an X-ray is performed to ensure healing of the repair.

Substitution Procedures
  • Free Graft Procedures: Longer strictures may be repaired with a free graft procedure to enlarge the urethra. The graft may be skin (usually removed from the shaft of the penis) or buccal mucosa removed from inside the cheek. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.
  • Skin Flap Procedures: When a long stricture is associated with severe scarring and a free graft would not survive, flaps of skin can be rotated from the penis to ensure survival of the newly created urethra. These procedures are complex and require a surgeon experienced in plastic surgery techniques. Brief hospitalization and catheterization for two or three weeks are usually required after this procedure.
  • Staged Procedure: When sufficient local tissue is not available for a skin flap procedure and local tissue factors are not suitable for a free graft, a staged procedure may be required. The first stage in a staged procedure focuses on opening the underside of the urethra to expose the complete length of the stricture. A graft is secured to the edges of the opened urethra and allowed to heal and mature over a period of three months to a year. During that time, patients urinate through a new opening behind the stricture, which in some cases will require the patient to sit down to urinate. The second stage is performed several months after the graft around the urethra has healed and is soft and flexible. At this stage the graft is formed into a tube and the urethra is returned to normal. A small, soft catheter will be left in the penis for 10 to 21 days.

What are the possibilities of recurrence?

Because urethral strictures can recur at any time after surgery, patients should be monitored by an urologist. After removal of the catheter, follow-up of the repair should be performed intermittently with physical examination and X-ray studies being performed as necessary. Sometimes, the doctor will perform urethroscopy to evaluate the repaired area. Some patients will have recurrence of stricture at the site of the prior repair. These are sometimes mild and require no intervention, but if they cause obstruction they can be treated with urethrotomy or dilation. A repeat open surgical repair may be needed for significant recurrent strictures.

*Content from this page obtained from Urology Care Foundation

Urinary Incontinence

Also called: Overactive bladder

Urinary incontinence is loss of bladder control. Symptoms can range from mild leaking to uncontrollable wetting. It can happen to anyone, but it becomes more common with age.

Most bladder control problems happen when muscles are too weak or too active. If the muscles that keep your bladder closed are weak, you may have accidents when you sneeze, laugh or lift a heavy object. This is stress incontinence. If bladder muscles become too active, you may feel a strong urge to go to the bathroom when you have little urine in your bladder. This is urge incontinence or overactive bladder. There are other causes of incontinence, such as prostate problems and nerve damage.

Treatment depends on the type of problem you have and what best fits your lifestyle. It may include simple exercises, medicines, special devices or procedures prescribed by your doctor, or surgery.

Low Testosterone

The human body functions within a relatively narrow range of normal. When chemicals such as hormones fall outside those normal levels, there can be consequences that affect the body at a cellular, organ, or systemic (body-wide) level.

Blood tests used to measure testosterone are usually performed in the morning. Testosterone sampling is difficult since the levels normally tend to bounce around a fair bit during the course of the day. The normal value for total testosterone in males is 270-1070 ng/dl. However, this depends to some extent on the individual laboratory being used, and the range can vary as a result. In women, there is debate about the accuracy of testosterone measurements, because the circulating values are so much lower than in males and are harder to accurately measure.

With advancing age, in both men and women, the amount of testosterone the body produces gradually falls. Free testosterone levels can be measured and normal levels depend upon an individual’s age. Interestingly, menopause itself does not seem to play a role in a reduction of testosterone levels in women beyond that of advancing age.

What are the causes of low testosterone?

Low testosterone levels may be caused by a number of factors. For example – there may be a problem at the level of the hypothalamus or pituitary to produce appropriate amounts of LH and FSH to stimulate testosterone production. Another possibility is that the organs that make testosterone do not function normally or are not able to respond to stimulation by the brain. Also, as mentioned, changes in SHBG can account for the amount of testosterone that is available to exert its effects.

When the problem is in the organs that produce testosterone (the ovaries or testes, for the most part), it is called a “primary” problem”. In medical terminology, the decrease in normal testosterone production is called “hypogonadism.”
When the problem is related to the pituitary and its ability to regulate testosterone, it is called “secondary hypogonadism,” and
If the problem is thought to be at the level of the hypothalamus, it is called “tertiary hypogonadism.”

Erectile Dysfunction

Also called: ED, Impotence

Erectile dysfunction (ED) is when a man has trouble getting or keeping an erection. ED becomes more common as you get older. But male sexual dysfunction is not a natural part of aging.

Some people have trouble speaking with their doctors about sex. But if you have ED, you should tell your doctor. ED can be a sign of health problems. It may mean your blood vessels are clogged. It may mean you have nerve damage from diabetes. If you don’t see your doctor, these problems will go untreated.

Your doctor can offer several new treatments for ED. For many men, the answer is as simple as taking a pill. Getting more exercise, losing weight or stopping smoking may also help.

UTI’s – Urinary Tract Infections

The urinary system consists of the kidneys, ureters, bladder and urethra. Infections of the urinary tract (UTIs) are the second most common type of infection in the body. You may have a UTI if you notice:

  • Pain or burning when you use the bathroom
  • Fever, tiredness or shakiness
  • An urge to use the bathroom often
  • Pressure in your lower belly
  • Urine that smells bad or looks cloudy or reddish
  • Less frequently, nausea or back pain

If you think you have a UTI, it is important to see your doctor. Your doctor can tell if you have a UTI by testing a sample of your urine. Treatment with medicines to kill the infection will make it better, often in one or two days.

No-Scalpel Vasectomy

A vasectomy is surgery to cut the vas deferens, the tubes that carry a man’s sperm from his scrotum to testicles. After a vasectomy, sperm cannot move out of the testes. A man who has had a successful vasectomy cannot make a woman pregnant.