Patient Education

The Genitourinary Tract

The genitourinary tract is comprised of two kidneys with one ureter each. The ureters drain into the urinary bladder which is then emptied into the urethra which exists the body. In males the seminal vesicles and prostate make seminal fluid which empties into the urethra through the ejaculatory duct.

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Benign Prostatic Hyperplasia (BPH)

As men age it not uncommon for them to experience changes in urinary function. These changes are commonly associated with abnormal enlargement of the prostate gland which typically begins in the late 40s or early 50s. The prostate encompasses the urethra, the tube that drains the bladder and runs the length of the penis. As the prostate enlarges, the diameter of the urethra becomes smaller, leading to change in flow of urine through the urethra. Symptoms of BPH include:

• decrease in strength of the urinary stream
• frequency of urination
• waking at night to have to urinate
• the sensation of incomplete bladder emptying
• hesitancy when initiating urination
• inability to postpone urination

BPH can usually be treated with medication alone. Two types of medications exist for treatment of BPH - alpha-blockers (Flomax, Uroxatral, Cardura, etc.) and 5-alpha reductase inhibitors (Avodart, Proscar). Alpha-blockers decrease the muscle tone of the prostate leading to improvement in urinary flow through the urethra. 5-alpha reductase inhibitors decrease the size of the prostate over time, leading to improvement in urination. Your Urologist will determine if medications are appropriate for you and will select the most appropriate medications for your specific condition.

At times, BPH is more severe and treatment with medications is not successful. Patients who fail medical therapy may be candidates for surgical treatment. Surgical treatments range from office procedures to procedures performed in a hospital setting. The standard of care for over 30 years has been TURP (Transurethral Resection of the Prostate) which involves removing abnormal prostate tissue via a scope placed in the urethra. More recently Laser Prostatectomy has been proven to have similar benefits to TURP with potentially less side effects and shorter hospital stay. Your Urologist will determine which procedure is best suited to help you.

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Kidney Stones

Stones may form within the kidney and cause severe pain, nausea, vomiting and blood in the urine. Stones lead to pain when they become lodged in the ureter and cause blockage that leads to distention of the ureter. This distention causes the symptoms associated with kidney stones. The pain associated with kidney stones typically starts in the flank and may radiate to the front of the abdomen and even to the groin.

Kidney stones can be diagnosed with IVP or CAT Scan. If a stone is present, medications may be prescribed to keep the patient comfortable and to facilitate passage of the stone. If the stone does not pass or if the pain is too much to tolerate, then a surgical procedure may be recommended.

Treatment options include ureteroscopic management and shockwave therapy. A ureteroscope may be placed into the bladder and then into the ureter where the stone is lodged. Lasers and baskets may be used to break the stone and remove the fragments. Typically a ureteral stent is placed after ureteroscopic procedures. When stones are higher in the ureter or within the kidney, shockwave therapy may be performed. This utilizes shockwaves that are safely passed through the body and act upon the stone to break it into numerous, passable fragments.

Following treatment of kidney stones your Urologist will decide if a metabolic workup is necessary to help prevent further stones. This typically involves a 24 hour urine collection as well as some blood tests. Your Urologist will then counsel you on prevention strategies possibly including dietary changes and/or medication.

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Bladder Cancer

A common location for cancer within the urinary tract is the urinary bladder. The chance of having bladder cancer within a lifetime are 1 in 30 for a man and 1 in 90 for a woman. Nearly 90% of people diagnosed with bladder cancer are over the age of 55. Bladder cancer is also more common in Caucasians and smokers versus their peers.

The earliest sign of bladder cancer is usually blood in the urine. It is not normal to have blood cells in the urine. Your urologist will decide if it is necessary for you to undergo cystoscopy to look inside of your bladder. This will determine whether cancer is present or not. Other potential signs of bladder cancer include frequency, urgency, and new onset of leakage of urine.

If a tumor is found within the bladder a Urologist will take a biopsy of the tumor. The results of this biopsy are important in determining the next step in the course of action. There are two main factors when determining the severity of bladder cancer - depth of invasion and grade.

How deeply a tumor invades is important when selecting the most appropriate treatment. Tumors that are on the surface of the bladder and that do not invade into the bladder wall are typically treated with resection and at times with the instillation of drugs into the bladder. Tumors that invade into the deep layers of the bladder are typically more aggressive and may require that the bladder to be removed for adequate treatment of the cancer.

The grade of the tumor also predicts the aggressiveness of the bladder cancer. While low grade tumors may be resected and monitored, high grade tumors may require the bladder to be removed. The combination of depth of invasion and tumor grade are considered together when deciding upon the best course of treatment.

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Kidney Cancer

Kidney cancer effects 1 in 75 people over their lifetime. It is more often found when an ultrasound or CAT Scan are performed for other health reasons. Kidney cancer rarely has any signs or symptoms. Rarely, kidney cancer will present with pain in the flank and/or blood in the urine.

There are many treatment options for kidney cancer. The most appropriate treatment is selected based on the size of the tumor, the location of the tumor within the kidney and the overall health status of the patient. Laparoscopic surgery has gained acceptance for the treatment of kidney cancer. Laparoscopy can be employed to remove the entire kidney, only the tumor itself, or to allow for freezing of the tumor. When a very large tumor is found, a traditional, open surgical procedure may be necessary.

In most cases kidney cancer is found early and the only necessary treatment is surgical removal of the cancer. Radiation and chemotherapy are traditionally ineffective in treatment of kidney cancer. Newer oral drugs (sunitinib or sorafinib) are given in more advanced stages of kidney cancer and work by suppressing a genetic defect that turns off one of the body's normal tumor-suppressor genes.

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Testicular Cancer

Cancer of the testicle is of the least common malignancies of the genitourinary tract. Approximately 8,000 men are diagnosed with cancer of the testis each year. Fortunately, less than 400 of those men will die from the disease.

Risk factors for testicular cancer include history of an undescended testis, family history of testis cancer, and white race. Men in their third to fifth decades are most at risk for testis cancer.

It is recommended that all men examine their testes monthly. If any abnormalities are noted, he should consult his physician immediately. Early detection and treatment lead to improvement in survival from testicular cancer should a tumor be found.

Treatment for testicular cancer includes removal of affected testis. Depending on the stage and type of tumor found further treatments can include chemotherapy, radiation, and surgery to remove lymph nodes.

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Urethral / Upper Urinary Tract Cancer

Cancer can occur within the ureter or renal pelvis. The cells that line these areas are the same type that line the urinary bladder. Cancer of the ureter is usually detected after blood is found in the urine or blockage is seen in the ureter. The standard treatment for ureteral cancer is removal of the kidney, ureter and a cuff of the bladder that surrounds the ureter. This procedure, nephroureterectomy, can be performed via an open or laparoscopic approach. Cancer of the ureter or renal pelvis can also be treated with a laser via a ureteroscopic approach. A scope can be placed into the bladder and then the ureter to the affected area.

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Urinary Incontinence (Leakage of Urine)

Involuntary loss of urine (urinary incontinence) is a very common problem, especially in females. There are many treatment options for incontinence which include medications and surgical treatments. Our specialists are skilled in performing the latest procedures should this be necessary. To understand which treatment is most appropriate for you, it is first necessary to understand that different types of incontinence exist.

Urge incontinence occurs when a person experiences the urge to urinate but cannot voluntarily postpone urination leading to leakage. This is usually able to be corrected with medications. Rarely, with severe cases of urge incontinence, medications may not help to correct the leakage and an implantable bladder "pacemaker," called Interstim™, may be the only treatment option. This device is placed beneath the skin of the lower back as an outpatient procedure (see the photos below).

Stress urinary incontinence occurs when a person experiences involuntary loss of urine when coughing, sneezing or exerting oneself. This type of leakage is typically corrected with an outpatient surgery with minimal discomfort. Prior to surgery, additional testing is performed in the office to confirm that surgery is the most appropriate treatment. This testing, urodynamic testing, involves placement of a small catheter in the bladder, a small catheter in the rectum and electrode stickers on the perineum. A series of coughing maneuvers is performed and bladder pressures are determined.  The procedure lasts approximately 30 minutes and is typically tolerated very well.

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Vaginal Vault Prolapse

As pelvic muscles age and lose strength, a women may notice "bulging" in the vagina which may be a sign of vaginal vault prolapse. Your Urologist will perform a pelvic examination to determine if prolapse is present and if so, to what degree. This problem may be corrected either with placement of a pessary device or with a surgical procedure. A pessary is a soft, rubber device that is placed within the vagina to correct prolapse. This is placed in a physician's office and needs to be cleaned regularly. Patients who desire surgical correction can now undergo minimally invasive procedures using mesh to correct prolapse. These procedures utilize small incisions at the inner thighs and inside the vagina and can often be done with an overnight stay in the hospital. Ask your Urologist if you are a candidate for minimally invasive vaginal vault prolapse surgery.

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Hematuria (Blood in Urine)

Blood in the urine, or hematuria, is a common reason for consultation with a Urologist. Normal urine does not show blood. If blood is found and there is no current urinary tract infection, a Urologist may deem it appropriate to order tests to determine the cause of this blood. Causes of hematuria include stones in the urinary tract, tumors of the bladder, ureter, kidney or urethra, as well as other benign causes. A Urologist will likely perform three tests to determine a cause for blood. These include urine cytology (a laboratory test to look for abnormal cells in the urine), cystoscopy (looking in the bladder with a small scope) and some form of X-ray to evaluate the kidney to rule out stones or tumors. It is especially important for patients over the age of forty and those who use tobacco products to have a thorough evaluation.

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Erectile Dysfunction

As men age, they may begin to experience changes in their ability to achieve an erection leading to difficulties with intercourse. A normal erection occurs when blood infiltrates the erectile tissues in the penis leading to rigidity. Failure of this blood to enter or remain within the erectile tissues can lead to poor quality of erections.  Some common risk factors associated with erectile dysfunction include advanced age, cigarette smoking, obesity, diabetes, high blood pressure and the use of certain medications to treat high blood pressure.  There are a variety of treatment options for erectile dysfunction ranging from oral medications to surgical treatments.

Oral medications for the treatment of erectile dysfunction encourage normal blood flow to the penis, allowing for an erection.  Name brands of this type of medication include Viagra, Cialis, and Levitra.  It is important to tell your doctor if you are taking a medication within the Nitrate family of medications as these can interact with oral medications for treatment of erectile dysfunction and cause serious side effects.

Injectable medications involve the injection of a medication into the erectile tissues of the penis to encourage normal blood flow to the penis.  These are generally reserved for patients who fail medical treatment.

Vacuum erectile devices are externally placed cylinders which a patient places around the penis.  A pump is used to draw blood into the penis to cause an erection.  An occlusive band is then placed around the base of the penis to trap the blood within the penis. It is important to remove this occlusive band immediately after completion of intercourse.

Penile prostheses are surgically implanted devices that assist in creation of an erection via an artificial pump that is hidden in the scrotum.  By pumping fluid into the erectile cylinders of the prosthesis, the penis becomes rigid, creating an erection.

Ask your doctor which treatment of erectile dysfunction is right for you.

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Vasectomy

Men who desire permanent sterilization often elect for vasectomy or ligation of the vas deferens (the tube which transports sperm). This procedure is typically performed in the setting of the office but may also be performed at a surgical center as an outpatient procedure. It is important for patients to know that while reversal techniques are available, that vasectomy should be thought of as a permanent sterilization as techniques to reverse the effects of vasectomy are not always successful.

Typically the skin of the scrotum is numbed with lidocaine and 1 or 2 small incisions are made in the scrotum. The vas deferentia are delivered through the incision, cut, cauterized, and tied to prevent sperm from passing through. Despite these measures there is still a <1% chance that pregnancy can be achieved following vasectomy.

Patients who undergo vasectomy should use birth control measures until no sperm are visualized in semen analysis. It is not uncommon for sperm to be seen initially in semen analysis and for a repeat semen analysis to be ordered.

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Vasectomy Quiz

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Cystoscopy

Cystoscopy is a commonly performed procedure to evaluate the urinary bladder and the urethra. A Urologist performs this procedure to evaluate for tumors of the bladder, stones in the bladder, or abnormalities of the prostate or urethra. This procedure is commonly performed in the office setting with use of numbing jelly for patient comfort.

This procedure is performed with a small, flexible scope and usually last 1-2 minutes. Most patients state that cystoscopy is not painful but causes an uncomfortable sensation.

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Da Vinci^® Robotic Prostatectomy

There are numerous options when considering treatment for prostate cancer. One such option is surgical removal of the cancer utilizing a minimally invasive approach via the da Vinci^® Surgical System. The da Vinci^® robot assists the surgeon in performance of laparoscopic removal of the prostate. It allows for extremely fine hand movements that mimic the human hand and 3-D visualization. The advantages of robotic prostatectomy are that it typically allows for:

• less loss of blood
• less pain after the procedure
• less time spent in the hospital
• more rapid return to normal activity
• less time with Foley catheter in place
• excellent, 3-D visualization of the neurovascular bundles which are related to retaining erections following surgery

Ask your doctor if da Vinci^® Robotic Prostatectomy is right for you.

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Prostate Cancer Facts

Know Your Stats

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Advanced Prostate Cancer

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Ureteroscopy

Ureteroscopy is a commonly performed procedure which utilizes a small diameter scope to look inside the ureter. This procedure is performed to diagnose and treat disorders of the ureter such as stones or tumors. It is common for a Urologist to place a ureteral stent following ureteroscopy. The procedure of ureteroscopy usually causes swelling of the ureter. A stent prevents blockage of the ureter while the swelling goes away.

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Shockwave Therapy for Kidney Stones

Your Urologist may recommend the use of shockwaves to treat stones within the urinary tract. Shockwave Lithotripsy has been commonly used since the 1980s and is a relatively safe and easy way to remove kidney stones. Newer devices have replaced the older "tub baths" and do not require a patient to be submerged into water. The patient is placed under anesthesia and onto a water cushion on the machine and shockwaves are delivered to the stone. This causes fragmentation of the stone into numerous small fragments leading to easy passage of this "sand" through the bladder. Occasionally, stone fragments may be large enough that they become lodged in the ureter and are unable to pass. This may require an additional procedure to remove the fragments but is not a common occurrence.

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Laparoscopic Surgery

Laparoscopic surgery involves the use of small instruments placed through small incisions to allow patients to have a more rapid recovery. The abdominal cavity is filled with air and the surgeon uses a camera to work inside the abdominal cavity. Images from the camera are projected onto monitors in the operating room and the surgeon views these images.

The advantages of laparoscopic surgery over conventional, open surgery are:

• shorter hospital stay
• less pain
• smaller incisions
• shorter overall recovery time

Laparoscopic surgery has many applications in the field of Urology. Since the 1990s laparoscopy has gained acceptance for treatment of many Urological conditions. Some procedures that are currently performed laparoscopically include laparoscopic nephrectomy, laparoscopic partial nephrectomy, laparoscopic cryoablation, laparoscopic prostatectomy, daVinci Robotic prostatectomy, laparoscopic adrenalectomy, laparoscopic pyeloplasty as well as many others. These procedures as well as many others are performed by the surgeons of N.E.O. Urology. Our staff offers a large amount of experience with laparoscopic surgery as well as fellowship training in the field.

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UroLift^®

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Prostate Biopsy

A Urologist may recommend biopsy to rule out cancer of the prostate for patients with an elevation of their PSA or if there is concern over an abnormal finding on rectal examination. This is typically performed in the setting of the office and is generally well tolerated by most patients. The prostate gland is best accessed via the rectum. Prostate biopsy is performed with the assistance of transrectal ultrasound by placing a probe into the rectum so that the prostate may be visualized. The urologist will administer lidocaine to make the procedure more comfortable for the patient. Measurements of the prostate are taken and the entire prostate is visualized to look for any abnormality. A series of needle biopsies are taken and sent to a pathology laboratory where a pathologist determines if cancer is present.

In preparation for biopsy of the prostate most Urologists will administer an enema the evening before as well a series of antibiotics to prevent infection. It is normal to experience blood in the urine, stool and semen after biopsy. It is not normal to feel ill or have a fever after biopsy. If this occurs it is important to notify your doctor immediately.

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MRI Fusion Biopsy of the Prostate

This form of prostate biopsy utilizes previous MRI images and real-time transrectal US images fused together along with an electromagnetic tracking system to precisely target predetermined lesions on the prostate.

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Ureteral Stents

It may be necessary for a Urologist to place a stent within the ureter. The stent is a small tube that is approximately 25 cm in length that spans the entire length of the ureter. These stents are not permanent and it is important for them to be removed or changed in the event that a stent is needed long term. A stent is typically removed in the office or as an outpatient procedure by placing a small scope into the bladder and grasping the stent to remove it.

While ureteral stenting is often necessary, especially after surgery involving the ureter, ureteral stents may cause discomfort to a patient. Symptoms of stent discomfort include feeling the frequent urge to urinate, pain in the side with urination, blood in the urine, and abdominal discomfort. These symptoms subside soon after the stent is removed.

Visit UrologyHealth.org for more information on urologic conditions and treatment.